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T 1 1 E

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

EDITED BY

I. MINIS HAYS. A.M., M.D

NEW SERIES

VOL. X( VI.

PHILADELPH I A :

LEA BROTHERS &

1888.

Entered according to the Act of Congress, in the year 1888, by

LEA BROTHERS & CO.,
In the Office of the Librarian of Congress. All rights reserved.

MAR 91966

1056234

i ii i i a Dl I. I'll i a:

DOKNAN, PIISTIII,

r. Scvonth and Arch Str**ta,

CONTENTS.

ORIGINAL COMMUNICATIONS.

PAGE

it-ma. Four Cases, with Two Autopsies. By Henry Hcn, M.D. With a
Report of the Microscopical Examination. By T. Mitchell Pkudden, M.D. . 1

Contribution to the Diagnosis and Surgical Treatment of Tumors of the Cerebrum.

By H. F. Weir, M.D., and E. C. Sequin, M.D 25

On the Influence of Bodily Movements over Septic Absorption. By J. Braxton

Hi. in, M.D. Lond., F.R.S., F.R.C.P 37

Simple Ulcer of the Duodenum. By W. W. Johnston, M.D 42

REVIEWS.

A Treatise on Diseases of the Skin. By James Nevins Hyde, A.M., M.D. . . 55

Traite .le fhirurgie de Guerre. By E. Delorme. 56

Ophthalmic Surgery. By R. Brudenell Carter, F.R.C.S., and W. A. Frost, F.R.C.8. 59

. !..al Diseases of the Genito-urinary Organs. By E. L. Keyes, A.M., M.D. . 62

The Intestinal Diseases of Infancy and Childhood. By A. Jacobi, M.D. . . 63
Hydrophobia. By Bernard Suzor, M.B., CM. Edin., and M.D. Paris ■ ■ .63
A Movable Atlas, showing the Progress of Gestation, by means of Superposed

< '.J.. red Plates. By Professor Witkowski, M.D 64

PROGRESS OF MEDICAL SCIENCE.

THERAPEUTICS.

Relation <>f the Atomic Weight to
Biological Action
Aoti.>n of Spirits <>n the Liver
Oleander [Nerium Oleander]

iiarceine
Solphonal ....
Treatment ..f Venereal Diseases

Antipyrin in Whooping-cough .
Vntipyrin versus Analgesine

65 Salicylate of Soda in Albuminuria

66 For Nasal Catarrh

66 " Magic Cream" (Lowndes)

67 i Menthol Plaster ....
U

68
68
68
N
69
68

MEDICINE.

Typhoid Fever in Children
The Incubation of Measles
Diphtheritic Throat in Scarlet Fever

irical Fever
Pathology and Therapy of Leukteinia
Arterial Tension in Neurasthenia

A. id Headache .
The Mortality of Epilepsy .

<>n Pneumonia .
Double Pneumonia Occurring simul-
taneously in One Family

69 Investigations on the Means of Dilfu-

70 sion of the Tubercle Bacillus .

70 On the Determination of the Limits

70 of the Heart by Percussion .

71 The Chemical Diagnosis of Diseases

72 of the Stomach ....

i alysis in Dysentery
13 Intussusception Relieved by Hydro-

73 static Pressure

Hematuria Simplex in a Newborn

U Child

CONTENTS.

SURGERY.

Pulmonary 8urgery .

Rectal Insufflation of Hydrogen in
the Diagnosis of Intestinal Wounds

The Influence of the Kidney in Pro-
ducing Vesical Symptoms

Imperforate Anus .

Open Incicision in Wry Neck, Con-
tracted Knee, and Talipus Varus .

PAOE

s.'i

Rectal Carcinoma .

Treatment of Fracture of the Patella

Luxation of the Fibula

Arthrectomy

Wound Treatment ....
The Treatment of Gonorrhoea! Rheu-
matism by Electricity

PAIJB

83
84
86

87
88

OTOLOGY.

Diseases of the Ear in General Diseases
Treatment of Boils in the Ear .
Aural Epilepsy Compared with other

Epilepsies

Tubercular Syphilide of the Auricle .
Ivorj Exostosis Removed from the

External Auditory Canal
Photoxylin Solution as a means of

Closing Persistent Perforations in

the Membrana Tympani

'.in

'.U

Tuberculosis in the Ear

Iodol in Otitis Media Purulenta

The Use of Lactic Acid in Chronic

Purulent Otitis Media
Surgical Removal of the Malleus
Case of Thrush in the Middle E;ir
Disease of the Middle Ear, Compli-
cated by Intracranial Lesions.
Alterations in the Labyrinth in
Measles

HI
91

92
92
93

DISEASES OF THE LARYNX AND CONTIGUOUS
STRUCTURES.

Acute, Infectious, Phlegmonous Pha-
ryngitis 94

External Incisions in Retropharyngeal
Abscess 96

Spontaneous Expulsion of a Laryn-
geal Polyp 96

Subhyoid Cyst with Displacement of

the Larynx 97

The Action of Caustics on the Nasal

Mucous Membrane .... 97

Acute Tonsillitis 97

Unusual Case of Laryngeal Papilloma 97

OBSTETRICS.

Puerperal Mastitis ....

Cesarean Section at the St. Petersburg
Maternity

The Relative Frequency and Causes
of Foetal Positions ....

Pregnancy with Gangrenous Ovarian
Cyst and Peritonitis ; Ovariotomy

A Fatal Case of Early Tubal Pregnancy

Involution of the Puerperal Uterus .

Puerperal Septicaemia from Atmos-
pheric Infection ....

The Lower Uterine Segment

'.hi

100

100
100

The Electrical Treatment of Ex

rine Pregnancy ....

Parturition among the Poor

Accidents with Bichloride of Mercury

Hydatid Cysts of the Uterus

The Causes of Hydrmnnios

The Treatment of Pregnancy Compli-
cated by Ovarian Cyst .

Birth Palriea

Ruptured Tubal Pregnancy Occurring
T\\ toe in the Same Patient

GYNECOLOGY.

Recto- vaginal Fistula*

Peritoneal Drainage by Iodoform-wick

The Treatment of Veaico- vaginal Fi-
tulie

The Operative Treatment of Dilata-
tion and Relaxation of the Urethra

Successful Case of Ovariotomy oa the,
Second Day after Delivery

vernous Degeneration ••t"th«> Ovaries
•ites as a Symptom of Torsion of the
Pediole in Cases of Ovarian Cyst .

104 The Corporeal Endometrium in Carci-

noma of the C«m\ ix Uteri

105 Observations on Pyoaalpinx
Laparotomy for Myoma of the Uterus

nil
101
101

101
101

102

105

lOli

107
107
108

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

JULY, 188 8.

MYXCEDEMA.

FOUR CASES, WITH TWO AUTOPSIES.

By Henry Hun, M.D.,

professor or diseases or THE nervous system and of psychological medicine in the

ALBANY MEDICAL O01UCT.

WITH A REPORT OF THE MICROSCOPICAL EXAMINATION.

By T. Mitchell Prudden, M.D.,

DIRECTOR OF THE LABORATORY OF THE ALUMNI ASSOCIATION OF THE COLLEGE OF PHYSICIANS AND SURGEONS,

NEW YORK.

FIRST PAPER.

Tin: following four cases are typical examples of myxoedema, and
their publication may, perhaps, contribute toward the solution of some
of the doubtful points in the pathology of the disease :

Case I. — Aug. 16, 1884. Mrs. M., set. fifty-three ; family history is
very imperfect, but none of her relatives, so far as is known, ever had a
disease similar to hers. Has had five children. They were all cross-
births, and were all born dead except the second, who is now a girl
of fifteen, and who is troubled with psoriasis. Has never had any severe
sickness and has always been strong and healthy. Menstruation ceased
four or five years ago, and since that time her face, body, and extremi-
ties have been very much bloated, and her eyesight has steadily failed.
Her hair has fallen out a great deal, and she is frequently chilly, although
at other times she has a very distressing burning and pricking sensation
over the skin of the whole body. She suffers much from cold and fre-
quently has cold sweats at night. During the past year she has been
much troubled by vertigo, a roaring in her ears, insomnia, and occipital
headache. Her speech is slow and difficult. Her mind is dull and con-
tused and her memory poor. She is much troubled by dyspnoea, and
when in bed she is obliged to lie on her left side in order to breathe

VOL. 96, NO. 1.— JULY, 1888.

2 HUN, PRUDDEN, MYXEDEMA.

easily. She feels no pain in her chest, but has a sense of oppression in
the upper sternal region, and complains of a pain behind the top of the
sternum in swallowing. She complains greatly of an uncomfortable
burning lemation in the left hypochondrium. Her bowels are regular.
Her urine is scanty and causes a burning pain on micturition. Her
appetite is fair. Food, especially ale, causes much bloating of the abdo-
men. She takes from one to two tablespoonfuls of gin three timet a
day. Her face, hands, and legs appear as though oedematous. These
parts, however, do not pit upon pressure but are firm and elastic. Her
complexion is waxy. Her speech is slow, hoarse, and monotonous. Her
mind is dull and she answers questions slowly. Abdomen is large and

Smlulous, otherwise abdominal and thoracic examination is negative.
er movements are sluggish, but there is no paralysis of motion or sensa-
tioii. Urine is straw-colored and contains neither albumen nor sugar.

Nov. 14, 1886. I have not seen the patient during the past two years.
Her appearance does not differ materially from what it was two years
ago. The swollen appearance of the skin remains unchanged, the eom-

f)lexion is waxy, with a spot of livid congestion on each cheek, the eve-
ids are baggy, wrinkled, and translucent; there is a ridge above the
inner half of each eyebrow, each naso-labial fold is continued up across the
nose by a band of thickened skin just above it, the nose is broadened,
the lips are smooth, thickened, and everted. The tongue is swollen and
the mucous membrane of the mouth and pharynx pale. The mucous
membrane covering the arytenoid cartilages and the false vocal cords is
pale and swollen ; the vocal cords are yellow, swollen, and do not com-
pletely meet in phonation, leaving a small oval between them at their
middle. The skin of the hands and legs is similarly swollen and wrinkled
and is scaly and of a slightly yellow tinge. The skin of the fingers is
thickened and they cannot be completely extended. Plate I. (Fig.-. 1
and 2) is taken from photographs of this patient's face and hands. None
of the swollen tissues pit except upon very deep and long-continued pres-
sure. The hair of the scalp is thin ; no hair in axilke but some hair on
the pubes. The nails are small, ridged, and strongly curved. The teeth
are loose and brittle, portions of them breaking off frequently. Her
hands, feet, and face, and especially her nose, are cold to the touch. She
sometimes sweats a little, but usually her skin is dry and rough. There
is no alteration in the secretion of her eyes or mouth, but her nose runs
a ::reat deal. Except for the pendulous abdomen, the thoracic and
abdominal examination urives negative results. No absolute paralysis
of motion or sensation, but she is weak and walking is difficult, and she
sometimes falls, so that she is afraid to walk in the street. Urine con-
tains a trace of albumen and a few hyaline and finely granular casts.
l'.u:eTRiCAL Examination. — Indifferent pole on the nape of the neck.

Intosh combined battery.)
Faradic current. All the nerves and muscles of face respond with
tube fully in.

Galvanic current. Measured in milliamperes (Gaiffe galvanometer).

Left. Right,

racial nerve trunk. - 0 AnS 8 AnO absent. - :< , AnS <)>.' AnO absent.

Fronul nmecle. \ ,,o i0.

I'll' other muscles of the face, although not tested so accurately, give
similar results.

HLN, PKL'DDEN, MYXCEDEMA.

80
minatioD <>f eyes by I>r. Merrill shows vision, right ., enmie-

XXX'

•_.,,

tropic ; left — , emmetropic. Range of accommodation good. All the

• 1 media are normal except the optic nerves and retinae; both
nerves are pule, the right showing slight atrophy. The retinae are
slightly hazy throughout their entire extent. The fields of vision show
Jit concentric limitation. K. Nitroglycerine gr. -^ t. i. d.
Feb. 20, 1SS7. At first the nitroglycerine seemed to afford her some
relief, but of late has produced no effect. She is gradually losing
Qgth. Complains of pain in pnecordia and of dragging pains in the
lower part of the abdomen (which latter feeling was much relieved by
an abdominal supporter), and that she can neither hear nor see well,
although this is not apparent on actual examination. R. Syr. hypo-
comp. Fellows), 5J t. i. d.
March 25. Has slowly grown weaker, and ten days ago her strength
out rather suddenly, and since then she has been confined to her
bed and requires much assistance to sit up in bed. The skin is more
Hen ami is scaly and rough. There appears to be a slight amount
of ascites. Her face is congested and looks as if she had fever. Her
temperature, taken on several occasions, is 98.4° in the mouth, and 98.2°
in the axilla ; pulse 73. A sphygmographic tracing of the pulse is
shown in Fig. 1. A week ago her respiration was irregular and exhib-
ited long pauses, but of late it is natural. An examination of the blood
shows 4,i »i H ».' )00 corpuscles in a cubic millimetre. Form of disks and ratio
d to white are not materially altered. Bowels are very constipated.
Urine sp. gr. 1015 and contains a faint trace of albumen.

Fio. 1.

June 10. Patient remained in about the same condition throughout
April, but in May she commenced to improve and has steadily gained
strength, so that at the present time, although still weak, she can get out
of bed without assistance and sits up most of the day.

Oct. 1. She continues to improve, walks about the room without
trouble, and has once or twice been down stairs. She is unable to do
any work. The skin of her hands is not as full and puffy as it was but
more wrinkled, and is loose and freely movable on the subcutaneous
tissues. The appearance of her face has not changed, but the hair on
her scalp has grown again and is much thicker. Her voice continues
rough and very hoarse, and she is very sluggish both in mind and body,
edema of the feet but a decided ascites. At times during last sum-
mer she sweat a little, but her skin is for the most part dry. Continues
to take a little gin daily.

try 22, 1888. Thi3 morning she suddenly became comatose, res-
piration slow and gasping, pulse of fair quality, deeply cyanotic. She
lay in this condition, passing water and feces in bed for about twelve
hours, and died to-day.

4 HUN, PRUDDEN, MYXffiDEMA.

I The daughter of the patient has had, during the past year, a very
severe attack of universal psoriasis, from which she made a complete
recovery, a couple of months ago ; but at present she is suffering from a
relapse. Her appearance is myxedematous.)

Autopsy twelve hours after death : Cheeks cyanotic, lips blue, breasts
large, skin of legs rough and scaly. No hair in axillae, scanty on pubes,
slightly scanty on scalp. Skin generally is of white color, and on sec-
tion shows nothing remarkable. Post-mortem rigidity slight. Scarcely
any hypostatic congestion. Normal layer of fat under skin of scalp.
Skull-cap of normal thickness, shape, and appearance, moderately ad-
herent. Both surfaces of dura mater appear normal. Very large
increase of subarachnoid fluid over surface of brain and at its base.
Pia mater normal, except that all its arteries, even to the most minute,
present numerous little yellow points due to thickening of their walls,
so that the smaller arteries look like chains of alternately opaque and
transparent beads. The larger veins of pia mater engorged with blood.
The basilar artery moderately, the carotid arteries extremely, thickened
and rigid. Ventricles of brain of normal size, except that the posterior
horns on both sides are obliterated. Choroid plexus pale, and appears
either cystic or gelatinous. Brain substance, perhaps, slightly oedema-
tous, cortex seems normal. Puncta vasculosa of white matter and of
ganglia at base well marked. In the superior anterior extremity of
body of cerebellum, and extending laterally a little into each hemi-
sphere, especially the left, is a small cavity filled with dark fluid blood.
A slight hemorrhage is seen on the outer edge of the right hemisphere of
the cerebellum, and scattered just beneath the surface of both hemispheres
of the cerebellum, especially the left, are numerous small patches of
dark blood, varying in size from a pea to the head of a pin. Choroid

f)lexus of fourth ventricle presents the same appearance as that of the
ateral ventricles. Sections through ganglia at base of brain are
normal. A thick layer of pale gelatinous-looking fat under skin of
back. Spinal cord appears normal on its surface.

A layer one and a half inches thick of pale gelatinous-looking fat
over anterior surface of body. Pectoral muscles seem pale and flabby,
and are infiltrated with fat. Pouch of fat in neck has, for the most part.
disappeared. About half a gallon of clear yellow fluid in abdominal
cavity. Position of viscera normal, except that the heart seems unusually
large, and the intestines are unusually inflated with gas. About half a
pint of clear yellow fluid in pericardial sac. Heart much dilated, and
the walls of the left ventricle very greatly hypertrophied, measuring from
three-quarters to one inch, the wall of right ventricle' being only slightly
thicker than normal. Auricles distended with dark blood, partly fluid
and partly clotted ; ventricles nearly empty. Tricuspid valve admits the
tips of three fingers, and the mitral valve the tips of two fingers easily.
Mitral valves very slightly thicker than normal. Aortic valves thick-
ened, and present some calcareous deposits at base, but the valves are
not sufficiently altered to interfere at all with their functional activity.
Muscular tissue of the heart appears pale, but otherwise normal. Cor-
onary arteries thickened and dilated. Arch of aorta generally athero-
matous, but no calcareous deposits. Universal firm adhesion of right
lung, and to a less degree of left. Hypostatic congestion of lower lobe
of left lung, but not of right (she lay on her left side during the last
twelve hours of life). Lungs otherwise healthy, and crepitate well.

HUN, PRUDDEN, MYXEDEMA. 5

Thyroid eland is smaller than normal, and presents several hard
nodules. Liver of about normal size, and slightly granular. Spleen
•boat normal Bize, capsule somewhat wrinkled, of firm consistence,
and trabecular unusually distinct. Large deposit of fat in mesentery
and omentum, Suprarenal capsules somewhat atrophied, cortices light
in color, and presenting small yellow spots. Both kidneys moderately
large, anaemic, cortex thickened and slightly opaque, cortical markings
and glomeruli unusually distinct. Capsules not adherent. Uterus, ova-
ries, and appendages normal, except for some senile atrophy. Numerous
small ecchymoses on wall of stomach. Urine drawn from bladder
twelve hours after death showed albumen one-third per cent.

Mh'koscopical Examination. — The tissues and organs were re-
ceived fresh and in good condition, and, for the most part, were
hardened in Midler's fluid, followed by alcohol. The hardened tissues
were imbedded in celloidin, so that the relations of the tissue elements
were not disturbed in the operation of section-cutting, nor in the sub-
sequent manipulations. The celloidin was allowed to remain in the
■actions, which were, in part, mounted in glycerine, in part in balsam ;
in the latter case the oil of origanum, which does not dissolve celloidin,
was used in clearing. The stainings were, for the most part, with hema-
toxylin and eosin.1 For the nervous system special methods of hardening
and staining were used, which will be noted below.

Fresh skin of abdomen; chemical examination. A determination of
the amount of mucin in a weighed quantity of the fresh skin and subcu-
taneous tissue of the abdomen was made in this case. This was done in
the usual way by digestion in baryta water; precipitation with acetic
acid ; redissolving of the washed precipitate in lime water and repre-
cipitation, then washing and drying. A control determination was then
made, by the same method at the same time, of the mucin in a like
quantity of skin and subcutaneous tissue from the abdomen of a fairly
well-nourished woman, who had been a moderate drinker, and died of
phthisis pulmonalis. A comparison of the results of the two analyses
showed that there was no more mucin in the same amount of skin in the
myxedema case than in the other.

Skin of bur/: and abdomen. There was a considerable and irregular
accumulation of superficial epidermis cells. The more superficial por-
tions of the papillary layer of the corium appear normal. But just
beneath the papilla?, in that zone of the corium in which the reticular
and papillary layers merge into one another, the lymph vessels are
dilated, and the interfibrillar spaces are widely open, so that the fibrillar
and the connective tissue cells stand out with unusual distinctness. The
smaller bloodvessels of the corium are, in many places, surrounded by
scattered collections of small spheroidal cells. The deeper layers of the
corium appear normal. The sweat glands are normal.

Scalp. The hairs and sebaceous glands appear normal. Atrophic
changes are not present. The distention of the inter-fibrillar spaces and
the smaller lymph vessels of the corium just described in the skin, is
even more pronounced in the scalp, as is the collection of small spheroidal
cells along the smaller veins and capillaries.

1 For the preparation of the sections and most of the drawings in this and the following case I am
indebted to Dr. Eugene Hodenpyl, Second Assistant in the Laboratory of the Alumni Association of
the College of Physicians and Surgeons, New York.

6 HUN, PKUDDEN, MYXEDEMA.

Fat. The subcutaneous and other fat tissue show a moderate degree
of atrophy, as indicated by the rounded contour, the pigmented proto-
plasm, and the evident nuclei of its cells.

The vokmtary muscles, as represented by the biceps and the pectoral is
major, appear normal.

The nervous system.1 The cortex, optic tiuUami, and corpora striata, are
normal. Portions subjected to Golgi's method, Weigert's method, and
to nuclear stains, such as carmine, hematoxylin, and eosin, exhibit no
abnormality in the arrangement and structural details of the ganglion
cells and their processes, nor in the distribution and number of the fine
nerve fibres in the giay matter. The perivascular and pericellular
spaces are not larger than in control sections of normal cortex hardened
in the same way, viz., Midler's fluid eight weeks, eighty per cent, of
alcohol without washing, absolute alcohol. Sections from many places
in the cortex, stained double and with acid fuchsin and by Golgi's silver
ami sublimate methods, show that the cortex is normal. There is no
increase in the neuroglia. Many of the bloodvessels of the pia and
cortex show in different degrees the lesions of a chronic obliterating
inflammation.

In and between the cerebellar folia are a number of hemorrhages from
one millimetre to one centimetre in diameter of comparatively recent
origin. These are in part meningeal, in part involve the brain tissue,
which is compressed and broken.

The nerve tracts and associated structures of the isthmus, crura, pons,
and medulla, were examined in detail, in carmine and Weigert's hema-
toxylin stained specimens, and were found normal.

Spinal cord. The anterior and posterior fifth, seventh, and eighth
cervical, the first, second, and twelfth dorsal, and the first and second
lumbar nerve roots, with sections from corresponding portions of the
cord, were fully examined (carmine, Weigert's, and Golgi's staining),
and were found entirely normal. The dorsal posterior roots were ex-
amined with especial care on account of their relations to the sympathetic
system.

Peripheral nerves. The trunk of the vagus, the upper and Lower
trunks of the brachial plexus on one side, and the radial and ulnar on
one side, are normal. Carmine and double staining reveal no inn
in the connective tissue, and in sections stained with Weigert's hema-
toxylin method the nerve fibres are intact and not diminished in num-
ber. The myelin in osmic acid stained portions of the radial and ulnar
nerves is intact.

Sinnpathrtir gj/ttem. The semilunar ganglia (left about 4 millimetres
by IB millimetres in diameter, the right about 3 millimetres by 22 milli-
metres in diameter' stained by Ranvier's gold method, by hematoxylin,
eosin. and carmine stains on both sides, and the great splanchnic on the
right side near its junction with the semilunar ganglia, are normal.
The middle cervical ganglion (thyroid ganglion) (three by five milium
in diameter and the inferior cervical ganglia nine millimetres in both
diameters), are normal. The ganglion cells are not shrunken, a few are
pigmented, and the connective tissue is not inereas - . ral of the

a* preparation of the sections, and for the examination an.I rapnrl ,m U) t-in, in

thin an.I in the following case, I am Indobted to Dr. Ira T. Van Oleaon, First Assistant in the Labora-
tory of the Aluiunl Association, College of Physicians and Surgeons, New York.

HUN, PBUDDCN, M VX<K1»K M.\ . 7

numerous branches of !>*>t li of these ganglia were examined, and are
normal. A portion of the trunk of the synipathetie above the thyroid
ganglion is normal.

Tin- muscles apppear normal. The coronary arteries ami
their branches show a moderate degree of chronic endarteritis. Just
h the surface of the visceral pericardium are numerous scattered
collections of small spheroidal cells grouped around dilated bloodvessels
(see FiLr. 2 : these cells lie among the fibres of the pericardial con-
li-sue, and appear to be the result of local emigration; these
c > 1 1 • .'ctious of cells are widely distributed about the pericardium.

Fio. 2.

Section of external layer of heart muscle, with pericardium. Showing collection* of small spheroidal
cells about the bloodvessels.

The bloodvessels throughout the body, so far as examined, were the
seat of endarteritis, with more or less atheromatous degeneration. This
was well marked in the carotids, the thyroid, and the cerebral arteries.

Lungs. The lower lobe of the left lung shows distention of the vessels
with blood, and an accumulation of red blood cells in the air vesicles.
w i >f the branches of the pulmonary artery are the seat of a moderate
ee of amyloid degeneration.

ich. The small veins about the above-mentioned ecchymotic
s of the mucous membrane of the stomach, in both the mucosa and
submucosa, are distended and plugged with red blood cells, leucocytes,
and masses of blood plaques ; and the regions of the mucosa from which
they come show necrosis and superficial disintegration of both the fol-
licles and interfollicular tissue. Minute collections of small spheroidal
cells are found here and there in the subserous layers of the stomach,
around the smaller veins and capillaries, and blocking up the lymph
Is. Many of the smaller arteries of the submucosa show a con-
siderable degree of amyloid degeneration of the media, while others
show a swelling and proliferation of the endothelium.

n. This is apparently normal, save for considerable amyloid
aeration of the smaller arteries.

There is a slight increase in the interstitial tissue and a
moderate dilatation of the capillaries about the central veins.
The pancreas is apparently normal.

Kidneys. The convoluted tubules are in places moderately dilated
with compressed epithelium, but they are for the most part normal in
size, and their epithelium normal or swollen and unusually granular.
The lumina of the tubules contain, in many parts of the cortex, irregular

HUN, PRUDDEN, MYXEDEMA.

granular masses, hyaline droplets, and disintegrated epithelium. The
interstitial connective tissue is increased in amount, especially in streaks
and patches about the glomeruli and along the line of the interlobular
arteries. The smaller bloodvessels, particularly of the glomerular tufts,
are distended with blood. Many of the smaller arteries show a moderate
amount of amyloid degeneration.

The supra-renal capsules. Scattered here and there throughout the
interstitial tissue of the gland and grouped around the bloodvessels are
tiny dense collections of small spheroidal cells, resembling leucocytes.
A few circumscribed areas of fatty degeneration of the epithelium are
present. In most of these the degeneration is so excessive that the epi-
thelial cell spaces are widely distended and the lumina of the neigh-
boring bloodvessels obliterated. Some of the smaller arteries are the
seat of amyloid degeneration.

The thyroid gland. The thyroid gland is symmetrical in shape, but
very small and nodular. The lobes measure from one-third to one-half
an inch in diameter, and the entire gland weighs 112 grains. A small
cyst in one lobe, apparently formed from a group of dilated vesicles, con-
tains fatty cells, cholestearine crystals, and free fat droplets. It does
not seem necessary to describe in detail the minute lesions of the thyroid
in this case, since they were identical in character with those which will
be fully described in the case of Mrs. B. (Case II.), which was first
examined.

A large proportion of the atrophied gland was made up of dense con-
nective tissue, so that a transverse section across the lobes had the
general appearance represented in Fig. 3.

Fio. 3.

Transyfrse section through the largest part of one of the Intend lobes or the thyroid gland-
shout six times the natural siw.

There WSf the same accumulation of small spheroidal cells and of

lymphatic tissue about the remains of the gland lobules, ai will be

ibed in the next case, but in general the lymphatic tissue had

penetrated more deeply into the lobules. So marked was this change thai

te parts theeatire atrophied lobule was represented by a rounded

mate of lymphatic tissue, from one-half to one millimetre in diameter,

HUN, PRUDDEX, MYXEDEMA. 9

in which, buried among the small spheroidal cells in the reticular tissue,
a few small irregular clusters of granular disintegrating epithelium,
ie representatives of the glandular structures.

The following case occurred in the practice of Dr. A. McLane Hamil-
ton, of New York, who requested me to attend the case in the intervals
between his visits, and who has very generously allowed me to publish
the results of the examinations which I made of the patient during her
life and alter her death :

:: II— Sept. 17, 1886. Mrs. B., aged fifty-four. Her family
history is good, as far as is known, down to the present generation. One
of her brothers died of disease of the brain, one sister had convulsions in
infancy and since that time has been weak-minded, and her other
brothers and sisters are of a decidedly nervous temperament. The
patient had a severe attack of typhoid fever when twenty years old, but
since that time has been healthy. She is the mother of five children,
has had no miscarriages, and passed the climacteric four or five years
ago without any noteworthy incident. Very soon after the climacteric
her face commenced to be bloated and has continued to grow gradually
more and more bloated up to the present time. Since the climacteric
also she has become less and less active and more and more nervous and
hysterical. During the past six or eight months she has exhibited
slight mental impairment.

:ie present time she is constantly in a condition of great nervous
excitement, is continually walking about, will not remain seated, and
feels inclined to scream. She complains of much distress in her head,
cannot bear any loud noises, and is afraid of becoming insane. She
has but little appetite and complains of much distress in the epigastrium,
apparently due to flatulence, is slightly constipated, and her urine is
abundant. She scarcely perspires at all ; her mouth is dry and pasty ;
she has no tears, and it distresses her greatly that she cannot weep over
the death of her mother which took place recently ; her skin, especially
her nose, is constantly cold, and her hair is thin.

Patient is rather fleshy ; her complexion is waxy, with a spot of livid

n on each cheek. The face is swollen ; the eyelids are baggy,

wrinkled, and translucent ; there is a ridge above the inner portion of

each eyebrow ; the nasolabial fold is continued up over the nose by a

thick ridge of tissue just above it ; the alse and tip of the nose are swollen,

the lips are swollen and smooth and the lower one everted. The tongue

ollen, and the whole mucous membrane of the mouth and pharynx

is anemic and covered with a dry, whitish mucus which feels so un

at that she is constantly rinsing her mouth with water.

The skin of the body generally is thickened, does not pit on pressure,
scaly, has a slightly yellowish hue, and is cold to the touch, especially
the nose, hands, and feet. At the outer edge of the right eyebrow there
■ a patch of chloasma, and on the scalp are large yellow patches of
. cuticle, and the skin of the axilla? is of a dark brown almost black
color, otherwise there is no pigmentation except the faint yellow tinge of
the entire skin. The hair on the scalp is rather thin; there is no hair
in the axilla? : she has a very few hairs on the chin, and the fine hair on
the body is well developed. The nails are well formed, except that

HUN, PRUDDEN, MYXffiDEMA

some of them are grooved longitudinally and they are very brittle. No
thyroid gland can be felt. There is no abnormal compressibility nor
mobility of the trachea. There is a large fatty tumor in the supra-
clavicular fossa on each side of neck. Thoracic examination gives
negative results. Abdominal walls are greatly distended, relaxed, and
pendulous. The liver is dislocated downward and is abnormally
movable. Urine contains neither albumen nor sugar. Sensibility, re-
flexes, smell, taste, hearing and sight are normal. All movements are
sluggish and a little weak. Speech is slow. When she speaks in a
shrill key her voice is fairly clear, but when in a deeper tone her voice
is rough and hoarse. Pulse is 68, small. A sphygmographic tracing is
shown in Fig. 4. Examination of the blood shows 3,806,000 corpuscles
in a cubic millimetre. The appearance of the corpuscles and the ratio
of the red to the white are not materially altered.

Fig. 4.

Electrical Examination. — Indifferent electrode on nape of neck.
Faradic current. Macintosh combined battery.

Facial nerve trunk in front of

Orbicularis palpebrarum mus-

Krtmtal muscle.
Zygomatic muscle.

Eight.

All muscles respond with the
tube fully in.

Responds with tube fully in.

Responds with tube fully in.
Responds with tube fully in.

Left.

All muscles respond with tube
withdrawn % inch, and all but
the muscles supplied by the in-
ferior branch respond with tube
fully in.

Responds with tube fully in,
and from this motor point of the
orbicularis the frontal muscle
also contracts with tube fully in.

Responds with tube with-
drawn ':; inch.

Rescinds with tube with-
draw ii 7S inch.

In general, the muscles of the right side not only respond to weaker
currents, but are also quicker in their contraction, the muscles of the
left side acting rather sluggishly and continuing for some time in a
state of contraction, as is also the case in a less degree with those of the
right side. This sluggish contraction of the muscles disappears when
strong currents are used, and is more noticeable with the faradic than
with the galvanic current. There is no apparent reason why the frontal
muscle should contract more readily from the motor point of the
orbicularis palpebrarum muscle than from its own motor point.

Galvanic current Measured in milliamperes (Gaiffe galvanometer).

D > rve trunk.
• irliic Dajpeb. muscle.
Ki'Mital muscle.
Zygomatic muscle.

Right.
KaS 31 4 AnS 10 AnO absent.

AllOfi'.,.

KaS 2 AnS 3% AnO absent.
KaS 8 AnS 9>2 AuO absent.

Left.
- 9 A uO absent.

\ nS 6 Ann a!
KaS 9 AuS 11 AnO absent.

In 1877, and again in 1881, Dr. Merrill examined the patient and
fou ml vision ' ' in each eye. An examination by Dr. Merrill at the

lit time shows vision - in each eye, not improved 1>

BUN, PRUDDIN, MYXiEDEMA,

h eye shows a manifest h\j>ernietropia of j*ff. Tension of the globes
normal, range of accommodation good, and the action of the external
ocular muscles perfect Color perception perfect. Fields of vision show
a marked symmetrica] limitation (see Fig. 5). The ophthalmoscopic
examination shows the media to be clear, a slight atrophy of the optic
nerves, and some oedema of both retime which is uniformly diffused over
the whole retina.

Fio. 5.

'70 150 17°

Diagram of the field of vision.

From Sept. 14th to 23d numerous temperature observations were
taken, which showed a lower temperature on the left side of from two
to four-tenths of a degree ; the axillary temperature being from one-half
to one degree below the normal.

R. Elixir ferri lact. sj t. i. d. R. Nitroglycerine gr. J^th four times
a day, to be increased in a few days to gr. ^yth t. i. d. Patient was also
given, as occasion required, a sedative mixture containing bromide of
potassium and cannabis indica.

Oct. 14. In many respects there is decided improvement. She is less
nervous and restless, is less disturbed by noises, has more control over
herself, is willing to see a few friends, and goes out driving. Her mouth
and tongue are less dry, her pulse is fuller, her skin is warmer than it
. her temperature normal, and she occasionally perspires a little.
Her mind is weaker and more childish. Her walk is weak and awk-
ward and at times she would fall were it not for her nurses.

. Since the last record she has refused to take any medicine. Has
had no hallucinations, but now for the first time exhibits delusions. She
maintains that her eyes have no longer their normal appearance, that
she cannot really see and is afraid to go to sleep because she is convinced
that she will awake entirely blind. She complains of much backache.

. At noon to-day a decided change took place. The expression of
her face greatly altered and she has the appearance of a bewildered,
insane person. She exhibits many delusions ; she says that she cannot
see, that her throat is rapidly closing so that she cannot swallow, and
that she cannot talk ; she says a few words perfectly distinctly and then
repeats such sounds as ga, ga, ga, ka, ka, ka, gee, gee, gee, au, au, au,

12 HUN, PBUDDEX, MYXCEDEMA.

hi-i-i-, etc. She complains of pain in the right hypochondrium and con-
stantly keeps her body strongly bent over to the right side. She is
extremely wild and excited and constantly in motion.

Nov. 8. She still refuses to take any medicine and for the past two
days has refused food, although after much persuasion she took a little
to daw She continued to be very excited and delirious till the first of
this month, when she passed into a condition of stupor or bewilderment.
She was very dull and her mind acted very slowly; more than a minute
elapsed after a question was asked before she answered it. This quiet,
dull condition only continued a few days, and of late she has been steadily
growing more and more excited, and yesterday and to-day she has been
very insane. She is sure that the dead bodies of her children are lying
up-stairs because she can smell them. Everything about her she thinks
is poisoned and she is afraid either to eat or drink.

18th. Since the last record she has taken no nourishment whatever
until to-day when she took a little fruit. Her abstinence from food,
which started from the delusion that everything was poisoned, has been
continued by the delusion, which has been very prominent during the
past week, that she is very poor and has no right to eat food which she
cannot pay for. On account of this delusion of poverty she is constantly
trying to pack up a few of her things and leave the house. The skin
seems colder to the touch, but the temperature is 98.8° in both axillae
and 100° in the rectum.

Dec. 8. The swelling of her face and hands has seemed to vary a little
during her sickness from time to time, and is now rather less than it was.
She no longer complains of any dryness of the mouth nor does it seem
to be dry, and there is often a free discharge of water from the mouth,
but no tears. She perspires at times, and once her body was covered
with sudamina. During the past month she has been entirely oblivious
of the calls of nature; she does not soil herself, but never panes cither
urine or feces unless the nurses sit her on the closet and tell her to do so.

Jan. 21, 1887. During the past month the patient has continued to
be much confused. She has slept but little and has been very restless,
and much of the time violent and delirious. Her pulse and temperature
have continued normal. During the past week she has had much diar-
rhoea and has become weak and emaciated, and the masses of fat on
each side of the neck just above the clavicle have disappeared. During
the past month she has been given two or three nutritive enemata every
day when the condition of the bowels would allow of it. Yesterday she
was so weak that she remained in bed all day ; last night she became
comatose, and this morning she died.

. 1 a fopsy, seven hours after death. Post-mortem rigidity marked. Blight
hypostatic congestion. Moderate amount of subcutaneous ii|t of dark
M How color. Very little blood in the tissues and organs. Each lobe
of the thyroid gland was a flattened ovoid body measuring one. three-
quarters, and half an inch in its three dimensions. The fatty tumors

had disappeared from the side of the neck. The right lung was free

from adhesions, the left being strongly adherent posteriorly and to the

diaphragm- Slight oedema of inferior lobe of each lung, the upper hoe
being anaemic Pericardium empty, righl ventricle flabby, left firmly
contracted and slightly bypertrophied, considerable sub-pericardia] fat

which has a gelatinous appearance. Surface of liver somewhat granular,
sections of the organ appear normal, gall-bladder lull of dark-green bile.
Spleen is firmly adherent tO diaphragm, its capsule is thickened, and the

HUN, PRUDDEN, MYXEDEMA. 13

whole organ a contracted and dense, measuring four and two and a half
inches. The suprarenal capsules are atrophied. The kidneys show well-
marked lobulation, their capsules are rather adherent, their surface on

hi appears normal. The ovaries are white and atrophied. There
are several small fibroids in the uterine wall. The mesentery contains
: i it 1 1 amount of yellow fat, no mesenteric glands are visible. The
intestines contain several large lumps of hardened feces. The scalp
•pt for the thinness of the hair) and the calvarium appear normal.
Both the small and the large veins of the pia mater are distended with
blood. There is a large amount of subarachnoid fluid over the surface
of the brain, and there is a general narrowing of the convolutions which
is especially marked at the posterior part of the superior parietal lobule
on the right side. Sections through the hemispheres and the ganglia at
the base reveal nothing abnormal except a general oedema. The ventri-
cles are of normal size and appearance.

Microscopical Examination. — The portions of tissues and organs
received had been hardened in Midler's fluid and alcohol, -and were
well preserved. Blocks of the various parts were embedded in celloidin,
and the sections stained with hematoxylin and eosin.

wetem. The cortex of the brain and the cerebellar folia are
normal. With carmine, hematoxylin, and eosin double staining the
perivascular and pericellular spaces are not enlarged, and the ganglion
cells present their proper topography and structural details. With
Weigert's method the fine fibres in the gray matter are not diminished
in number. Neuroglia not perceptibly increased. The isthmus and
spinal cord are normal. A portion about one-half millimetre in diameter,
of the nucleus cuneus is detached and lies external and posterior to the
lateral angle of the nucleus.

and fat. In the skin of the abdomen and thigh the layer of
superficial epidermic cells is thick and irregular, the cells being in part
packed in dense layers, in part lying in loose, more or less voluminous
shreds.

The delicate fibrillated fibres of the papillary and subpapillary layers
of the corium are unusually distinct, and appear as if they were or had
been crowded apart by some homogeneous material the nature of which
I am unable to determine. Thus while the outer layers of the corium
appear relatively thicker, they are less dense than normal, and there is
no apparent increase either of the fibrillated or the elastic fibres. The
deeper layers of the corium appear normal. There are small, irregular,
and scattered collections of small spheroidal cells, which have the appear-
ance of leucocytes, about the smaller bloodvessels of the more superficial
layers of the corium. The bloodvessels contain about the usual amount
of blood, do not appear compressed, and are apparently normal. The
sweat glands are normal.

Fat. The subcutaneous fat of the abdomen and thigh differs from
normal adult fat in that the individual fat cells are in places unusually
distinctly outlined, and present more or less rounded contours, while
distinct intercellular spaces are abundant. Large, distinct nuclei and a
zone of protoplasm are frequently present in the fat cells; while about
the nuclei, in many cells, is a small accumulation of yellow granular
pigment. The fat tissue has thus in general more the characters of
atrophic or embryonic fat than that of well-nourished individuals. This

TOL. 96, KO. 1.— JILT, 18S8. 2

HUN, PRUDDEN, MYXEDEMA.

condition of the fat is, however, not uniformly present, but appears only
in scattered areas.

The scalp. The superficial layer of the epidermis is thick and irregu-
lar. While a portion of the hairs appear normal, a large part of them
present various phases of atrophy.

From some of the follicles the hairs are absent, and the follicle is
represented by an irregular elongated mass of cells. In others the bulb
is atrophied, and is merged with the papilla into a dense irregular knot
containing but little pigment (Fig. 6, a.) Passing upward from this is a
solid mass of cells, irregularly packed together, replacing both the shaft
and the root sheaths (Fig. 6, b). The dermic coat of the follicle, on the

Fki. 6.

•"• \ ;

■ML

. X

Atrophied hnir follicle from scalp, a, atrophied bulb mid papilla; b, d«ep portion of follicle: 0,
thickened dermic coat ; d, hyaline degeneration Jn dermic coat ; «, false bulb Aran which the hair
grows, without a papilla.

other hand, is thickened and unusually dense in texture, and the inner
laver of that portion just above the bulb is converted into an irregularly
tabulated hyaline mass containing few nuclei (Fig. 6, d . Above this
the hair shaft takes its origin in a large bulging mass of epithelial cells.
representing the cells of the outer root sheath, but is without a papilla.
These maybe called false hair bulb* (Fig. 6, c). The outer root-sheaths
above the false bulbs are frequently rough and irregular in their contours.
The sebaceous glands are in treneral much atrophied, and lie betide the
hair follicles in the form of irregular, narrow, cylindrical hags, contain-
ing but few — not infrequently a single row — of the characteristic

HUN, PRUDDEN, MYXCEDEMA.

tuiy cells, or in some cases none at all. Not infrequently slender,
ssory hairs originating near the mouths of the sebaceous glands, in
small false bulbs, issue obliquely from the atrophied follicles. There are
collections of small spheroidal cells about the smaller bloodvessels of
the corium, but the bloodvessels appear otherwise normal. We have
thus in the scalp the lesions of simple alopecia.

The heart shows a moderate amount of dense connective tissue in
patches beneath the surfaces of the papillary muscles of the left ventricle
ami extruding in streaks into the muscle tissue. The heart is otherwise
normal.

The tubpericardial fed presents in much more marked degree than
the subcutaneous i'at. the lesions of atrophy of the fat cells, so that
they exhibit in their rounded contours, in their large, well-formed
nuclei and protoplasmic disks, and in their wide, intercellular spaces, a
most marked embryonic type.

tplt in shows a moderate thickening of the intima of the smaller
arteries and considerable hyperplasia of the reticular stroma of the pulp.
The glomeruli are normal.

The liver shows an irregular thickening of the capsule and a con-
siderable increase in the interlobular connective tissue, which is richly
■applied with small spheroidal and fusiform cells. There is a moderate
degree of fatty infiltration ; there is no increase in the lymphatic nodules
of the liver.

Fig. 7.

rtion of atrophied thyroid gland. Low power, a and b, atrophied lobule*; <% new-formed lymphatic
tissue in the periphery of lobules.

The kidneys show a considerable increase in the interstitial tissue or
the cortex, especially about the glomeruli and along the lines of the

rlobular arteries; this new connective tissue is, for the most part,
richly cellular. The tufts of the glomeruli are frequentlv replaced by
dense knobs of connective tissue. There is, corresponding to the in-

ised amount of interstitial tissue, atrophy of the uriniferous tubules.
Many of the convoluted tubules are dilated, their epithelium flattened

HUN, PRUDDEN, MYXEDEMA

or disintegrating at the free borders, or absent. Hyaline casts are
present in moderate number in the straight tubules.

The thyroid gland. The capsule of the very small, hard, and nodular
thyroid gland is denser in texture and thicker than normal, and contains
numerous small arteries and dilated thin-walled veins, and capillaries
which are in places greatly distended and irregularly pouched with
blood. The thickened capsule merges on the inside imperceptibly into
the dense interstitial tissue of the gland. The appearance of the lobes
of the gland itself, as seen in transverse sections, differs in marked
degree from the normal, not only on account of its greatly diminished
size, but because of the greatly increased amount of interstitial tissue in
proportion to the parenchyma (Fig. 7). The interstitial connective tissue
occupies from one-half to two-thirds of the section area in all parts of
the gland ; this interstitial tissue is, for the most part, dense and fibrillar,
and is irregularly distributed ; it contains numerous thin-walled blood-
vessels, which are in places distended and pouched with blood. Fusi-
form and small spheroidal cells are in general scattered in moderate
numbers among its fibres. In some places, on the contrary, the con-
nective tissue about the bloodvessels is densely infiltrated with small
spheroidal cells, having the appearance of leucocytes.

Fig. 8

- * ' 2*

Section from periphery of atrophied lobule of thyroid gland. Showing Irregularly brand -l.iml
resides, surrounded by lymphatic tisane.

HDN, PRUDDEN, MYXCEDEMA.

But it ia the parenchyma of the gland which presents the most marked
uihI striking alteration. Scattered here and there throughout the atro-
phied gland are little islets of gland tissue (Fig. 7, a), the largest from
three t<> lour millimetres in diameter, the smallest scarcely visible to the
naked eye. composed of a congeries of larger and smaller rounded or
'irregular-shaped vesicles, which are either regularly lined with moder-
ately granular, flattened, or cuboidal epithelium, or completely or nearly
completely filled with a multinucleated granular cell mass or a clump
of irregular shaped, more or less distinctly outlined cells (Fig. 8).
The vesicles or cell cavities possess a very thin membrana propria, and
an- surrounded by a regular capillary network. These masses of vesi-
okl apparently represent the lobules of the thyroid, and the larger
vesicles arc usually in the centre, the smaller in the periphery of the
lobules. A few of the larger vesicles contain colloid material.

Then there are somewhat similar lobules of gland tissue, so small as
to be generally invisible to the naked eye, whose vesicles throughout
are very small, and for the most part completely filled with irregular
granular cells Fig. 9 I. Two or three of these islets of gland tissue may
lie side by side, but they lie, for the most part, singly, and separated
from each other by broad bands of interstitial tissue.

Fig. 9.

a&1

.- ->«v

"■■'. "V*

;.'•'■

Very much atrophied lobule of thyroid gland. Showing masses of granular epithelium in place of the

normal vesicles.

Finally, scattered everywhere in the interstitial tissue, are large gran-
ular cells or cell masses (Fig. 10) which have the same morphological
characters as the epithelium above described in the larger and smaller
lobules, but lying singly.

In the periphery ot most of the islets of gland tissue, is a great accu-
mulation of small spheroidal cells, lying in the interspaces of a rich
vascular network i Fig. 7. c, and Fig. 8).

i his peripheral accumulation of cells is sometimes in the form of a
sharp-edged, narrow baud ; but is most frequently somewhat

HUN, PRUDDEN, MYXEDEMA,
Fio. 10.

Interstitial tissue of atrophied thyroid. Showing scattered epithelial cell
FlO. 11.

Shaken section from periphery of atrophied lobule of thyroid. Showing th« nwforiylng reticulum .>f
the now-formed lymphatic tlwue. a, nuclei of the ractlcuUr tissue.

HUN, PBUDDEN, MYXCEDEMA. 19

diffuse at the edges and extends inward among the gland vesicles in wedge-
ibaped masses or branching streaks. Where this small cell accumula-
tion is moderate in amount, the cells lie around the bloodvessels between
the fibrillatod fibres of* the interstitial tissue, or along the capillaries
between the gland vesicles, so that they appear as if due to an emigra-
tion of leucocytes. But where the accumulation is voluminous, an ex-
amination of from which the small spheroidal cells have been
removed by pencilling or shaking under water, reveals a most marked
and highly developed genuine reticular tissue quite similar, save for its
distribution, to that which forma the reticular framework of the lym-
phatic nodes Fig. 11). This reticulum has its distinct nodal points of
intersection upon which lie flattened cells with moderately large, round,
or ovoidal nuclei (Fig. 11, a). This reticular tissue merges, on the one
hand, into the fibrous interstitial tissue, and, on the other, into the small
amount of tissue accompanying the capillaries about the gland vesicles.

In a few places small masses of spheroidal cells lying in the meshes
of a tiny mass of reticular tissue were found, apart from the glandular
structures. These resemble the small masses of lymphatic tissue which,
as shown by the researches of J. Arnold, are normally present in various
organs — liver, lungs, kidney, etc.

We have thus in the thyroid, in addition to a relatively large amount
of interstitial connective tissue and an excessive atrophy of the paren-
chyma, an actual new formation in considerable amount of lymphatic
. both in isolated nodules and around the atrophied lobules.

For the opportunity of examining and reporting the following case, I
am indebted to Dr. Franklin Townsend, of Albany, whose patient he is :

-;■: III. — January 15, 1887. Mr. Y., aet. thirty-six, unmarried.
His father is healthy, but lethargic. The mother and the three children
all have a more or less myxoedematous appearance. The patient is the
oldest of the three children. He probably had syphilis about ten years
ago. He was thoroughly treated for it, and, finally, went to the Hot
ngs of Arkansas, from which he returned, in 1878, in first-rate
health. Between 1880 and 1884, he made several trips to Xew Mexico,
being interested in some mines, and during his last visit there he thinks
he contracted his present sickness. Before the disease made its appear-
ance he was in the habit of smoking to excess, and drank from twelve
to fifteen glasses of beer daily. He came to Dr. Townsend in August,
1884, for treatment on account of a scaly fissured eczema behind his
ears, and at that time he presented the following symptoms : His face,
lips, legs, and ankles were swollen and pitted somewhat on deep pressure,
his eyelids were baggy and wrinkled, there was a bridge of thickened
the nose, his tongue was so swollen that he talked with
great difficulty, and his voice was rough and hoarse. The skin of his
body was white except for a decided yellow tinge under the nails of the
finders and toes, and a patch of chloasma on the right temple and the
right side of the face. His skin was dry and itched somewhat, the epi-
dermis peeled off in great quantities, and his hair was brittle and broke
off in large quantities, about one-quarter of an inch above the scalp. His
actions were sluggish, and he was so weak that he twice fell in the street,
once when he was trying to catch a horse-car. His mind was sluggish,
it took him a long time to answer questions and his memory was poor.

20 HUN, PRDDDEN, MYKEDEMA.

A careful examination of the thorax and abdomen revealed nothing
abnormal, except a decided enlargement of the liver. Urine wafl
normal. Pulse about 60.

He was given iodide of potassium, grs. 40 t. i. d., which was increased
to grs. 90 1. i. d. This he took for about a month and seemed to improve
on it. He was not iodized by it, but, finally, it upset his stomach. A
little later he took arsenious acid, gr. ^ff t. i. d., increased in two
months' time to gr. ^ t. i. d. without any good effect. During these
three months of treatment his stools were always white. He then took
quinia sulph., pil. hydrarg., aa gr. j t. i. d., which caused his stools to
change to a light brown color. Still later he took a pill of ox-gall,
mercury, and quinine and then stopped taking medicine. From the
commencement of treatment, in August, the liver steadily decreased in
size.

The disease reached its height toward the end of 1884, and remained
stationary throughout 1885, the swelling of the face showing slight varia-
tions at times. In the spring of 1886 he commenced to improve, and
since that time he has been slowly improving in all respects. The face
is much less swollen than it was, and the swelling of the legs and feet
has disappeared entirely. The skin is less yellow than it was in 1885,
and the spot of chloasma on the right side of the face has nearly disap-
peared. His skin is less scaly, and he sometimes perspires now, although
for a long time he did not perspire at all. He is not quite so badly
affected by the cold as he used to be, and this winter he has remained
North, although every previous winter he has gone to the Southwest
with the advent of cold weather. He is physically stronger, his mind
is brighter, and he answers questions more promptly.

At the present time there is a slight yellow tinge to the skin generally,
which is especially marked over face and vertex of head. The skin is
scaly, the complexion is waxy, and on friction spots of congestion appear
on the cheeks and persist a long time. The whole top of the head appears
bald, but on close inspection is found covered with short, brittle stumps
of hairs. Eyebrows, moustache, beard, hair on body fairly well devel-
oped ; the hair being especially abundant on the front of the chest. The
nails are ridged, and he says they are extremely brittle, and on that
account trouble him greatly. The face is swollen, and pits only on long-
continued pressure. The swelling affects especially the lips, which miv
much everted, and of a bluish color, the nose and cheeks are also swollen,
and, to a less degree, the forehead ; the under eyelids are baggy and
wrinkled, but the swelling is much less than it was a year ago. The
tongue and soft palate, and, to a less degree, the hard palate, are ameniie
and much swollen. The mucous membrane covering the epiglottis, the
arytenoid cartilages, and the false and true vocal cords is anemic and
swollen. The epiglottis and vocal cords are less swollen than the other
parts, and present a slight, but evident, yellow tinge, and the vocal
cords do not meet perfectly in phonation, but leave a slight oval between
them near their centre. The two cords move symmetrically. No thy-
roid gland can be felt, and there is no history of any goitre. The trachea
is not particularly movable nor compressible. There is a slight fulness
above each clavicle, but no fatty tumor in that region. The patient is
weak. No disturbance of tactile, painful, or thermic sensibility. Plantar
reflex absent on both sides. Knee-jerk normal on both sides. Thoracic
and abdominal examination negative. Urine presents a normal appear-

BUN, PRUDDEN, MYXEDEMA. • 21

aiK f. no sediment, sp. gr. 1030, and contains neither albumen nor sugar.
An examination of the blood .-hows that there are 4,001,000 corpuscles to
the cubic millimetre, that the corpuscles are of normal appearance,
and that the ratio <>f tin- white to the red corpuscles is not materially
altered. A Bph^mograpEic tracing of the pulse is shown in Fig. 12.

Fig. 12.

Electrical Examination. — The indifferent electrode on nape of
neck :

Faradie current. All nerves and muscles respond with tube fully in,
the muscles of the right side contracting more strongly than those of
the left.

Galvanic current. Milliamperes (Hirschberg galvanometer).1

Bight. Left.

Facial nerve trunk. KaS 2 AnS 3 AnO 4. KaS 2% AnS 3% AnO 41 :,.

Frontal muscle. KaS 1% AnS 2 AnO absent. KaS 1 AnS 1% AnO absent.

Zygomatic muscle. KaS \% AnS 2 AnO absent. KaS 2% AnS 3 AnO absent.

The muscles respond with a quick contraction to each kind of elec-
tricity. 20
An examination of the eyes by Dr. Merrill shows vision: Right — ,

20 90 • XL

with correcting cvlinders vision is Left ", with correcting cyl-

20 xxx XI

iuders vision is

xxx

In 1877 the patient consulted Dr. Merrill on account of blepharitis

and asthenopia, which were found to be due to astigmatism, and were

corrected by proper cylinders. This refraction is the same now as then,

although the vision has failed somewhat. It was then, without glasses,

20 '^0

in each eve; and with proper glasses—-. On ophthalmoscopic
xxx xx

examination nothing abnormal was noted, except a haziness extending

throughout the entire extent of both retina?. The fields of vision show

a marked concentric limitation, almost as great as in the case of Mrs. B.,

Patient states that he has been constipated throughout his sickness.
He has noticed no alteration in the secretion of his eyes, nose, or mouth.
He now weighs 145 pounds, and never weighed more than 155 pounds.
He eats very little meat, and takes but little food of any kind. Pulse is
70 after walking. He sleeps well. His arms and legs used to be con-
stantly going to sleep, and even at the present time the region of the
distribution of the right ulnar nerve becomes numb, and goes to sleep
every night.

April 2, 1888. During the past year the patient has continued to
improve slightly.

1 The Gaiffe galvanometer used in the two former cases has been recently tested and found to be accu-
rate. When the Gaiffe and Hirschberg galvanometers are compared with each other, the former regis-
ters twice as high as the latter ; so that the numbers given in the third and fourth cases are probably
only one-half what they should be.

22 • HUN, PRUDDEN, MYXCEDEMA.

The following case was kindly referred to me by Dr. McLean, of Troy :

Case IV. — January SO, 1887. Mr. S., set. twenty-seven, unmarried.
His mother is healthy ; she had eight children ; two died in infancy, and
six are living. His father has not been able to work for several years
on account of disease of the kidneys. His oldest sister has heart dis-
ease ; another sister has Bright's disease, and his two other sisters are
affected somewhat as he is. He has always been weak, and could not
play as vigorously as other boys. When fourteen years old he had two
slight attacks of jaundice. His present sickness commenced when he
was eighteen years old, but exactly how, he cannot remember. He grew
steadily worse, till two years ago, since which time he has improved a
little. His sister says that up to the age of eighteen years his skin was
remarkably soft and white.

Patient now complains that he is so weak that he can walk only a
short distance. He is much troubled by dizziness and by pain in the
back. His feet and hands are cold and numb, and he cannot bear cold
weather. He always feels worse in hot weather, and he becomes much
bloated. At such times he cannot see his knuckles, and the wrinkles
disappear from the skin. When it is alternately hot and cold, the skin
becomes much wrinkled and cracked. At one time he had an abundant
crop of hair on his head, but now it has mostly fallen out, as has also
the hair on his body. He has a great deal of watery discharge from the
nose, a superabundance of saliva, and he also cries easily, having an
abundance of tears. The saliva seems to come especially from the right
side of his mouth, and his right nostril discharges much more freely than
the left, but he notices no such difference between his eyes. He is sub-
ject to hemorrhages, and has had some severe hemorrhages from the
nose, from the gums, and from the bladder. Almost every night there
is a discharge of watery blood from his mouth. His hearing is good,
but his sight is dim. His memory is poor; he is not troubled by head-
aches, and never had any delusions, nor anything resembling insanity.
He sleeps poorly, and is much disturbed by vivid dreams of an unplea-
sant character. No thoracic symptoms, except slight palpitation. Appe-
tite good ; some distress after eating ; bowels rather costive.

His appearance is dull and stupid. His speech is slow, hoarse, and
monotonous. The skin has a yellow tinge, and is swollen and wrinkled.
It does not pit except slightly after long continued and deep pressure.
The eyelids are baggy, wrinkled, and translucent ; there is a ridge above
the eyebrows ; the naso-labial fold is continued up over the nose by a band
of thickened skin above it : the lips are swollen and everted. The tongue
is much swollen, as is also the mucous membrane of the pharynx to a
less extent. The mucous membrane of the larynx appears only slightly
swollen, and the vocal cords are thickened, and not entirely approximated
in phonation. The entire mucous membrane is an semi c. The skin of
the body is covered with thick yellow scales. These scales can for the
most part be removed by hard and continuous rubbing, but they quickly
form again. They are on the face and scalp as well as on the body,
anus, and legs, and are especially thick and rough on the feet and on

Eosterior aspect of elbows. The hair of the head is extremely thin : tin-
airs are not broken off", but each hair is separated from its neighbors by
a large space. There are no hairs on his body, nor in the axilla, and
only a few hairs on chin and pubes. Plate if., Fig. 2, and Plate III.,

Plat* II., Fio 2.

Photograph of Mr. S. (Case IV.)

which was taken recently.

Plat* II., Fio. 1.

Photograph of Mr. S. (Cask IV.) which was
taken when the disease was commencing.

■■■ .

To fact page 22.]

HUN, PRUDDEN, MYIffiDEMA.

1 ami '_', show the present condition of his face, hands, and back
of head. Plate II., Fig. 1, is from a photograph taken when he was
•hoof twenty years old, when the disease was commencing. Abdomen
is distended, and rather pendulous, otherwise abdominal and thoracic
^nation is negative. He passes a large amount of urine which
contains a trace of albumen but no casts. An examination of the
blood ah K000 corpuscles in a cubic millimetre; the form of

the corpuscles and the ratio of the red to the white not being mate-
rially altered. Pulse slow. Fig. 13 is a sphymographic tracing of
the poise. All the patient's movement.3 are sluggish and weak. No
disturbance of tactile, painful, nor thermic sensibility. Plantar reflex
absent or greatly diminished. Knee-jerk faint. An examination of

the eyes by Dr. Merrill shows vision: Right - , Left — , not improved

' L XI.

by glasses in either case. The ophthalmoscopic examination was entirely
ive. The fields of vision showed a slight concentric limitation.

Fio. 13.

Ki.kctrical Examination. — Indifferent pole on nape of neck.

Faradic current.
Facial nerre trunk.
Frontal muscle.
Zygomatic muscle.

Galvanic current [Slilliamperee].
(Hirschberg galvanometer!.1
Facial nerre trunk.
Frontal muscle.
Zygomatic muscle. .

Left.
Tube fully in,
Tube withdrawn 1}

; inches.
, inch

Left.
KaS 2 AnS 3 \nO absent
KaS 1 AnS 2% AnO "
KaS 2 AnS 3 AnO "

Bight.
Tube withdrawn 1% inches.

xy «

,jl .«

Right.
KaS 2 AnS 3% AnO absent.
KaS i% AnS »£ AnO "
KaS2}£ AnS3)| AnO "

April 1. Patient took nitroglycerine, gr. ^th t. i. d., for a long time
without any benefit, and then Fellows's compound syrup of the hypo-
phosphites, with no better success. A single dose of pilocarpine, gr. -g^th,
caused obstinate vomiting and great prostration, without producing any
sweating.

7, 1888. He has not changed materially during the past
v. ar. although he feels better, and the skin of the legs and feet is less
Men and scaly than it was. He has been somewhat less troubled by
hi Iv saliva, but lately he has had frequent and severe nasal hemor-
rhages. Three years ago he had repeated discharges of bloody urine.
Is very dizzy, and i* so weak that he cannot go up stairs without the
aid of his hands. There is no impairment of tactile or painful seiiM-
bilitv. No retardation of conduction of sensory impulses. Plantar
rerli\ and knee-jerk normal. Gums extremely swollen and spongy and
bleed easily. Teeth are badly formed and loose, and occasionally one
falls out He says that the teeth get loose and then get tight again.
Temperature in rectum 98.2°; in mouth 97.7°; in right axilla 97.2°;
in left axilla 96.83 (same thermometer). A surface thermometer held
with moderate pressure on forehead registered 94°, but the reading
varied with the pressure from 92° to 98°. Urine, sp. gr. 1020, clear

t See foot-note to Case III.

24 HUN, PRUDDEN, MYXCEDEMA.

yellow, contains one-eighth per cent, of albumen, no sugar. Sediment
contained no casts, but a large number of red blood globules. His nose
continues to run a great deal ; whenever he bends his head forward drop
after drop of clear fluid falls slowly from tlie nose.

An elder sister of Mr. S., twenty-nine years old, has apparently re-
covered from a mild attack of myxoedema. She says that her skin has
always been rough, especially across the small of lier back and on the
inner side of her thighs and legs. At times her face is swollen, especially
under her eyes. She does not mind the cold weather, but dreads the
hot weather, because she becomes so hot and flushed. -She does not
perspire even in summer, unless she works hard, and when she perspires
her skin is softer. Two years ago she had an attack of jaundice, lasting
four or five months, and was confined to her bed most of that time, and
her hair fell out freely, and her teeth became loose. Since that time
her skin has been decidedly less rough. She frequently has a tired
feeling come over her, which compels her to lie down. She cannot
work in a factory because she gets so hot and flushed. She has never
had a goitre nor has any member of her family. She used to have, as
a girl, frequent and severe epistaxis, and she has always been unwell
very freely, much more than she thinks is natural. Her memory is
good. She has vivid dreams. She has a good crop of hair except in
axillae, where she never had hair. Her teeth are not decayed. Her
voice is not hoarse. Temperature in mouth at 8 p.m. 99.2° Her ap-
pearance is not abnormal, except for some thickness of the lips and
puffiness about the eyes, and a slight scaliness of the skin, especially on
inner side of thighs. She says that she is very much better than she
was, and she attributes her improvement to daily warm baths and ex-
cessive friction of the skin, which she has used with great energy for
Beveral years.

A younger sister of Mr. S., twenty years old, seems to be in the early
stages of a mild form of myxoedema. Her face has always been swollen
and her skin is thick and scaly. Hair of head has always been thin,
and has not grown much until recently. There is no hair in axilla?, but
the hair on the pubes is well developed. Her nails are not brittle but
are not well formed. No trouble with her teeth. She always has been
badly affected by the hot weather, she becomes hot and flushed and

Serspires only slightly. During the past winter she was much troubled
y chilblains on her feet, and her hands were deeply chapped and
fissured, although she went out very little. Her voice is clear. She
feels weak and languid. She has neither epistaxis nor menorrhagia.
Pulse 80, small ; temperature at 8 p.m. 100° ; urine sp. gr. 1005, trace
of albumen, the sediment contains no casts, but much vesical epithe-
lium. She complains especially of flushing and burning of face, which
looks flushed and swollen.

WEIR, SEiH'LV, CEREBRAL LOCALIZATION. 26

CONTRIBUTION TO THE DIAGNOSIS AND SURGICAL TREAT-
MENT OFT! FMOBfl OF THE CEREBRUM.

By R. F. Wkik, M.D..

EOS TO THE SEW TOBK HOSPITAL ; PKOrts*'>R ,,» K.JRRV IN Till COLLEGE OF PHVSICIAXS

AXD SUBGEONS, HEW TOBK.

A Nil

E. G Baaunr, M.D.,

MEMBER OF THE ASSOCIATION OP AMERICA!* PHTSICIAN8, ETC.
I.

Tin: case which forms the basis of this contribution to a novel field of

_ ioal progress, presents many points of interest in relation to diag-

>, and illustrates the possibility of the removal of a deeply placed

tumor, and the prolongation of life through operation. The medical

and surgical remarks upon the subject which the case illustrates are

separately made by the authors.

Hi -TORY OF THE CASE. [B\T Dr. SeGUIX.]

Mr. B.. :tt. thirty-nine, married, German, brewer, residing in Bridge-
port, Conn. ; attending physician Dr. Charles C. Godfrey.1 Was first
seen during my absence by Dr. J. Arthur Booth on August 12, 1887..
The following is a transcript of the notes then taken:

Is a strong-looking German. Has been married ten years ; has four
healthy children. Wife has had no miscarriages. There is no his-
tory of gonorrhoea, or chancre, or of any syphilitic symptom. Has
been in the habit of drinking beer, but no strong drink. Has smoked
moderately. Is right-handed. No epileptic attacks in childhood. Was
perfectly healthy until the autumn of 1882. He then had malarial
fever, apparently of mixed remittent and intermittent forms. During
this illness he had a good deal of pain in the head, and one day, feeling
strangely, he got up to go to the window, when his wife observed a
spasm of the right cheek and neck (head and face turned to the right).
This was a twitching spasm, and did not involve the arm ; consciousness
was not lost. A similar attack occurred a year later, and during the
third year he had an occasional attack in the night. She is positive
that until 1885 there were no spasmodic movements in the hand or arm.
He was otherwise well, with the exception of an occasional headache,
until two years ago, when one day he fell unconscious and bit his tongue.
He has had similar attacks at long intervals since ; they lasted only a few
seconds and left him very weak. These epileptic attacks were preceded
by an aura consisting of a "frightened feeling," followed by twitching or
jerking in the right hand and arm and in the right side of the face,
followed by loss of consciousness.

The attacks have occurred at all hours, and no exciting cause has
been observed. Has taken bromide of potassium lately, and has had

1 The authors of this paper desire to express their obligation to Dr. Godfrey for his hearty cooperation
in the management of this case, and for his skilful treatment of it during the long period in which it
was under his in liyi'lual caie.

26 WEIR, SEGUIN, CEREBRAL LOCALIZATION.

fewer attacks. Memory not as good as formerly, and speech has become
" thick " (bromide effect ?). General health has remained good.

Examination. — Stands well with eyes closed. No tremor of tongue
or fingers. Tongue deviates slightly to the right. Vision is good ; never
diplopia. The right hand is weak ; dynamometer showing R. 30° and
32° ; L. 35° and 32°. No ataxia. Patellar reflex normal. (State of
facial muscles not noted.)

Treatment. — To stop beer entirely ; to take twenty grains of bromide
of sodium morning and noon, and forty grains at bedtime.

August 26. Dr. Seguin's notes. Patient now states that the first
epileptiform attack was five years ago. A long interval follows, as
above noted. Again denies, in most positive terms, the occurrence of
chancre or any syphilitic symptom. No injury to head. Attacks always
begin in the right facial muscles ; speech is almost wholly suspended,
even when consciousness is fully preserved. Can call out "water" or
" ices," but cannot talk. He has had no motor attacks in the hand alone.
Patient is not aware of weakness of the right hand and arm, but admits
that he is awkward with this member, and that his handwriting 1ms
become bad. In the last eight or nine months the right upper extremity
has felt heavy or " numb." Speech is said to have been thick and slow
for over two years. Memory much impaired.

Examination. — Pupils equal, of medium size and active; muscles all
act well (no pri3in-test). The optic nerves and retinal vessels appear
perfectly normal. The lower facial muscles on the right side are dis-
tinctly paretic, and there is slight deviation of the tongue to the right.
Can close left eye alone, but not right ; frontalis normal. The right arm
is paretic ; grasp, R. 32° and 30° ; L. 33° and 35°. Stands equally well
on either foot; the walk is normal. Patellar reflex slightly greater on
the right side. Sensibility is unimpaired, except a very slight diminu-
tion of tactile sensibility, as tested by aesthesiometer, on the right cheek.
Mental action slow but accurate.

Recent attacks: about June 10th or 12th, August 11th, 16th, and
18th. Intermittent fever has reappeared ; a chill followed by high fever
on August 21st, 23d, and 25th.

Symptomatic diagnosis. — Right-sided Jacksonian epilepsy, with facio-
brachial paresis.

Anatomical diagnosis. — Tumor of the left motor zone in the facial
centre.

Treatment. — Ordered a mixture containing to each dose, Fowler's
solution, 5 minims; bromide of potassium, 20 grains; iodide of potas-
sium, 15 grains; fluid ext. of rhamnus frang., 3ss, on rising, after
midday meal, and at bedtime. For tertian fever, to take sulphate of
quinine 20 grains to-night, and 10 grains every night afterward.

September 21. Comes with Dr. Godfrey. Has had only one seven
epileptic attack since last call, viz., on August 31st. On September 17th,
had a slight localized attack in the right cheek. Speech is worse ;
slow and somewhat interrupted, though not, strictly speaking, syllabic.
The patient himself has noticed the aggravation, and adds that he can't
always think of the right word to speak. On September 13th. had a chill
followed by fever. During this attack he had severe pain in the left side
of the head. No constant headache; no vertigo. Complains of a con-
stant feeling of numbness, or a numb-weight in the whole of right upper

WEIR, SEGUIN, CEREBRAL LOCALIZATION. 27

extremity, but not in cheek, tongue, chest, or leg. Has been somewhat
-v in daytime.

o'lfih'mi. — Pupils and optic nerves are normal, right facial
muscles as before. Tongue tremulous, but nearly straight. Paresis of
right arm more pronounced : grasp, R. 36°, 37°, 37° ; L. 40°, 37°, 39°.
- ids less well on right foot (eyes closed). Patellar reflex is greater on
right ride

ability. No anaesthesia of face. On pulps of left fingers the
points of the a-sthesiometer are distinguished at from 2 to 3 mm., on the
right at from 3 to 5 mm. This slight tactile anaesthesia is most marked
on thumb and index. Feels texture of cloth as well with right as with
left fingers. The muscular sense, as tested by passive movements and
\veLrl)t>. when eyes are closed, is normal.

Ac desirability and feasibility of an operation in the near future, if
symptoms increase, are discussed with Dr. Godfrey. I feel reasonably
tin that the lesion is a tumor affecting the motor apparatus of the
left hemisphere, in the parts associated with the face and hand. Whether
the tumor is cortical or subcortical is open to doubt. The local twitch-
ing, or clonic spasm being in favor of a cortical lesion, while the absence
of (constant) headache would strongly point to a medullary lesion.

October 19. Has had several seizures. One (on September 23d),
beginning as usual in the right face, became a complete epileptic attack
with biting of the tongue. States that frequently after attacks the right
cheek is flushed and hotter than the left. Has had more severe and
more constant pain in the left parietal region. The hemi-paresis is
worse; saliva flows almost constantly from angle of mouth ; the right
cheek and buccal muscles are almost powerless ; the tongue deviates very
slightly to right (not at all in proportion to the facial paralysis) ; the
anaesthesia, though very slight, is demonstrable on right lace and hand ;
to coarse tests the muscular sense is normal in upper extremity. Per-
son develops tenderness over an oval area 2* x 2 inches above the
left ear, and overlying the motor zone. I advise an operation, ex-
ploratory at least, as soon as the patient can be induced to submit to it.
mber 15. Mr. B. comes to New York expressly to have the
operation performed. Since last date, a thorough trial of iodide of
potassium, to 200 grains three times a day (four days at that dose), has
been made, without good or bad effects. The bromide has been con-
tinued at an average dose of sixty grains per diem, but several partial
attacks have occurred.

A careful physical examination reveals substantially the same symp-
toms, viz., paralysis of ri>rht lower facial muscles, paresis of right arm
(grasp: R. 23°; L. 40°); leg apparently normal; constant drooling
from right side of mouth; slight aphasic and agraphic faults. Anaes-
thesia as before, tactile, and very slight; muscular sense preserved.
No symptoms in optic apparatus. The greatest tenderness to percus-
sion, coinciding with seat of greatest constant pain, is in a spot just
in front of the auriculo-bregmatic line, and from 8 to 10 centimetres
('■> to 4 inches) above the external auditory meatus.1 The patient was

1 This area of tenderness was marked at the time upon * cranial diagram, and subsequent comparison
of this sketch with that represented by Hg. 1, and with the estimated actual location of the tumor
at the time of operation, was made.

28 WEIR, SEGUIN, CEREBRAL LOCALIZATION.

sent to Dr. R. F. Weir to be examined by him with a view to operation,
and was admitted the same day to the New York Hospital as a private
patient in his service.

On the same day careful measurements of the cranial temperature
were made upon the shaven scalp. The instruments used were four of
a set of Seguin's surface thermometers, self- registering, made expressly
for me by Casella, of London, in 1883. These thermometers were not
graduated until four months after making, and Mr. Casella guaranteed
their accuracy. Just before using them to-day, I tested the entire set of
twenty instruments, comparatively, in water at about the normal tem-
perature of the body, and found that most of them agreed to T^° C,
and the others (with one exception) within i° C. Four of the most
accurate were used upon the patient; each instrument being held firmly*
upon the scalp (with enough force to leave an indentation) for five
minutes. The results were recorded by an assistant, while Dr. Gordon,
the House Surgeon, and myself managed the instruments. The follow-
ing is the tabulated result in Fahrenheit degrees.

Right side.

Left side

Frontal regions

. 93.2°

94.3°

Temporal regions ....

. 98.0°

96.0°

Vertex one inch from median line

. 96.8°

95.0°

Occipital region

. 94.1°

97.2°

Over supposed site of tumor

. 96.3°

97.7°

Right side.

Left side

. 95.0°

96.4°

. 97.2°

96.8°

. 96.4°

96.4°

. 96.4°

97.2°

. 97.7°

98.0°

. 96.8°

96.4°

. 96.1+°

96.1°

Nov. 17. The measurements were taken again in the same manner.
Temperature of room 78.5°. Axillary temperature of patient 97.7°
(hospital thermometer).

Frontal regions ....

Temporal regions

Vertex one inch from median line

Occipital region ....

Just above edge of ears

Half way up Rolandic line .

Over supposed seat of tumor

The averages of these measurements for the two sides of the cranium
were:

Right. Left.

First series 96.7° 96.0°

Second series 96.5° 96.75°

96.1° 96.37°

The temperature over the supposed seat of the tumor was 1.4° higher
on the left side the first day, but on the second day no differences of any
moment were noted.

For the whole head these averages were almost in accord with those
of Maragliano and Seppilli (96.98°), and higher than those of Gray
(95.5°). As the averages of Gray represent more nearly the norm*]
in our climate and in our inhabitants, we must conclude that in the
case of Mr. B. there was a general elevation of cranial temperature
amounting to about 0.7°.

WEIR, SEGUIN, CEREBRAL LOCALIZATION.

Then thermometrical results appear specifically worthless ; yet the
absence of positive elevation of temperature over the supposed site of
the tumor might be added to other indications to be referred to later,
and which led us to be prepared for a subcortical lesion.

Final diagnoti*, — It is almost certain that Mr. B. has a cerebral
tumor involving the centre for the face and partly that for the arm in
the left hemisphere. On account of the late appearance of headache,
and the absence of marked elevation of temperature over the seat of
the tumor, we must not be unprepared to find a subcortical tumor.
Nature of tumor uncertain, probably a sarcoma. The appended figure
is a reduction of an Ecker diagram with the probable site of the tumor
marked by a heavy ring, drawn before the operation, which was done

Fio. 1.

Outline diagram of lea hemisphere.

The dark ring represents the site of the tumor, estimated
before the operation.

by Dr. Weir on November 17th. The tumor was found, deep under the
surface of the brain, in the indicated location. Although, surgically
speaking, it was a subcortical tumor, yet it probably invaded the cor-
tical gray matter deep in the sulcus between the gyri {vide Figs. 3 and 4).

The Operation. [By Dr. Weir.]

The operation was performed with the assistance of Drs. Seguin and
Bull, under ether and with antiseptic precautions, spray included, Nov.
17, 1887. The patient's head, shaved the previous day, had been for
twenty-four hours covered with gauze moistened with 1 to 60 carbolic
acid, after a thorough scouring with whale-oil soap and water. The
auriculo-bregmatic line was marked out by Dr. Seguin on the scalp, and
at a point a little in front of this line and just anterior to the lower half
of the fissure of Rolando a minute perforation was made through the
scalp and through this a mark made with a sharp pencil to indicate on
the skull, when exposed, the place to be centred by the trephine. An
oval flap of the scalp, three inches broad and including the periosteum,
was then raised from the skull in such a way that its base was toward
the frontal region. This was held back by a suture at its apex to the
eyebrow, and the many arterial and venous bleeding points secured by
clamps. The first button of bone with a one inch trephine was re-
moved about one and a half inches above and a little in front of the
left ear. A second button of a similar size was taken away just in

vol. 96. no. 1.— jilt. 1888. 3

WEIR, SEGUIN, CEREBRAL LOCALIZATION.

front of this and a little above it. The intervening portions of bone
were rapidly gnawed away with a double gouge forceps, and the cranial
opening enlarged on all sides in the same way until it reached an area
of three by two inches.

The dura mater bulged only slightly but pulsated freely, and pre-
sented a normal appearance. It was opened by lifting a part with a
tenaculum and by first penetrating it with a knife, and then cutting it
with curved blunt scissors a quarter of an inch from the skull edge for
about three-quarters of the circumference of the hole, leaving the at-
tached part uppermost. This flap was then reflected (Fig. 2). One of

Fig. 2.

fuslair,! inrk
fy a Suture

h the

Brc*

K.fferM Dun „ \fa/rr

Diagram showing lines of incision and location of tumor.

the vessels of the pia was wounded in the procedure and was ligated after
some little difficulty. The middle meningeal vessels crossing over the
dura were secured, partly before the incision in this membrane, by a
curved needle carrying catgut through the dura, an expedient taught
me by my venerated preceptor Dr. Gurdon Buck, or by tying the vessels
as they were cut. Two branches at the lower part of the wound were,
however, only controlled by small sponges at first, and subsequently by
iodoform gauze pressed between the dura and the skull.

As the brain itself was exposed it was noticed to bulge decidedly into
the opening, but its pulsations were manifest. Nothing abnormal was
seen on the exposed surface, though by some it was supposed the convo-
lution situated most posteriorly was violet in color. This was thought,
however, by me, to be due to the recent extravasation (alluded to above)
from the damaged pia vessel. The finger recognized no tumor or ab-
normality. Quite nrm but gradual pressure, sufficient to permit the
finger to be carried below the skull level and slightly beyond the area
of the bone opening, furthermore revealed nothing. It began to appear

WEIR, SEGUIN, CEREBRAL LOCALIZATION.

as if the growth was beyond the reach of surgical art, when firm pres-
sure posteriorly encountered a deep resistance of a hard mass of small
size underneath the previously suspected convolution. The convolution
WM gently parted with the finger-nail and a director, and at a depth of
nearly an inch, directly inward and in probable close proximity to the
upper part of the ventricle a mass was exposed to the touch, and sub-
sequently indefinitely to sight by means of gently used retractors, made
of bent spoon handles. It was then ascertained to be a growth nearly
the size of a large almond, or, more correctly, in shape and size as large as
the end of the forefinger, not encapsulated and seemingly infiltrated into
the brain tissue. It was, after a brief trial to remove it with a director,
lifted out readily with a Volkmann's spoon one-half inch in diameter,
which had been previously blunted for the purpose.

After the tumor had been taken away a separate hard piece the size
of a pea was recognized and also removed. The finger could now be
passed to the depth of fully an inch and a half, and it gave me the im-
pression of being in a smooth cavity. No hemorrhage from the brain
itself occurred. The normal condition of the brain having been cor-
roborated by Dr. Seguin's digital examination, a rubber drainage tube
was carried to the bottom of the cavity and out through the posterior
margin of the wound. The dura mater was stitched together except
over a small area where the tube emerged, and after a final washing of
the wound with a 1 : 5000 sublimate solution had been done.

Fig. 3.

Fig. 4.

Fig. 3. — Outline diagram of left hemisphere, with ring showing topography of tumor.
Fijr. 4. — Diagram of oblique transection passing through tumor (Pitres's coupe froniale), showing the
actual location of the tumor as determined by the operation.

The disks of bone and a number of the bone fragments which had
been chipped off" by the rongeur were replaced over the sewn dura.
These disks and pieces of bone had been kept in a towel wet with 1 to 60
carbolic acid, and kept at a suitable temperature by immersing the jar
containing them in warm water for over an hour. Two strands of horse-
hair and one of catgut were placed under the replaced scalp for drainage,
and a fresh piece of iodoform gauze tucked between the skull and dura
mater at its lower part where the meningeal oozing was still troublesome,
and after suturing the scalp with catgut, a sublimate dressing dusted

32 WEIR, SEGUIN, CEREBRAL LOCALIZATION.

with iodoform, was applied with moderate pressure. At the termination
of the operation pulse 125. General condition good.

The tumor lay entirely within the white substance and was situated,
in the judgment of Dr. Seguin, at a depth of three-quarters to one inch
below the posterior edge of the second frontal and the anterior edge of
the precentral gyri ; that is, approximately in the fasciculus for the face.
This location in a transverse projection corresponds to Bitot's section
No. 3, and is a little behind Pitres's pediculo-frontal section. The loca-
tion of the tumor in depth is approximately represented by Fig. 4,
made from an oblique transection, corresponding with the frontal section
of Pitres.

Pathologist's Report. — The microscopical examination of the tumor,
made by Dr. Peabody, pathologist to the hospital, was as follows :

Sections of the tumor show it to be made up chiefly of round and oval
cells, with a rather abundant stroma of finely fibrillated connective
tissue. These cells vary in size from that of white blood cells to that of
three to four times their size. The superficial parts of the growth con-
tain numerous large bloodvessels with very thin walls. There is no peri-
vasculitis. On one side of the tumor there is a thin layer of white matter
(visible to the unaided eye) which is distinctly fibrillated, with cells like
those of the tumor itself. No glioma cells can be obtained by appro-
priate treatment. Diagnosis — Sarcoma.

During the operation there was more hemorrhage from the divided
scalp vessels than in my opinion should be hereafter allowed. Clamps
and ligatures hold poorly in the tough tissues of the scalp, and it is
believed that the use of acupressure needles, at least during the opera-
tion, would answer better. The operation lasted about one and three-
quarters hours, and was prolonged by the difficulties in controlling the
hemorrhage from the scalp, dura, and pia mater.

Three or four hours later, when the patient had come out of the ether,
it was noticed that he moved his right leg well, and his arm as before.
He was slightly aphasic, and his facial paralysis was somewhat more
marked. At 10 p.m. Temp. 99° ; resp. 24 ; pulse 132. Given sod. brom.
grs. xv. At 11.30 p.m. ordered peptonized milk, sj ; brandy, 5), q. 2 h.

18th. Given hypodermatic of Magendie, ^iij, at 1.30 a.m. Cathe-
terized at 2.45, 10 ounces of urine drawn. Was very restless during the
flight Vomited slightly at 8 a.m. Temp. 102° ; resp. 24; pulse 124.
Hypodermatic of antipyrin, grs. v, at 11 p.m. ; to be repeated every three
hours as long as the temperature keeps above 100°. Given milk and
lime-water, 3ij, q. 2 h.

19th. Vomited three times during the morning. Temp., a.m., 100° ;
resp. 22; pulse 112. Catheterized at 9 a.m. Milk continued as on
terday. Is fully conscious of everything going on around him. Aphasia
more marked than before the operation. Facial paralysis about the
Mine as before operation.

20th. Temp. 99 ; pulse 90. The dressings were changed to-day. and
as the rubber drain contained clots, suggesting the fact that it did not
drain well, it was removed. The one and a half inch thick dressing was
pretty well soaked with dried I >1<>< ><ly discharge. The horsehair drains
were also withdrawn, and only the catgut drain loft in. The iodoform
tampon was also removed. The scalp was found blistered, owing to irri-

WEIR, SEGDIN, CEREBRAL LOCALIZATION. 33

tant effect of the too damp bichloride compresses. This accounted, I
think, for the temperature in part at least. Carbolic spray used while
dressing waa done. Dry sublimate and iodoform dressings applied.
Decided improvement in patient this morning ; aphasia not nearly so
marked.

Id. This morning the temperature was 99.8°, resp. 20, pulse 90.
From this date the patient progressed steadily. A second dressing was
made on the 27th inst., ten days after the operation, when the whole
wound was found healed, save a small spot where" the drainage tube had
merged. The replaced bone appeared firm. The patient's aphasia had
nearly disappeared by this time, and his appreciation of a joke was quite
keen. By December 4th he was out of bed, sitting up. The scalp was
firmly united, the replaced bone disks solid, and the cranial gap entirely
occluded with bone, except at its lower part, where the fragments had
been dislodged by the emergence and withdrawal of the iodoform tampon.

Subsequent History. [By Dr. Seguin.]

The operation was followed by temporary complete paralysis of the
right limbs, and nearly complete aphasia. So marked was the last
symptom that, for a few hours, we feared that the third frontal gyrus
had been injured, but this fear proved groundless. From the day of
operation until November 24th, fifteen grains of bromide of sodium were
given at bedtime. On November 24th this dose was increased to thirty
grains. By a misunderstanding, no bromide was given from November
27th to December 3d, when he was ordered B., Sodii bromidi, £jss ; syr.
aurant. cort. ajss ; aqua, ad syj ; one teaspoonful (equal to seventeen
grains of bromide) three times a day.

I examined the patient at the New York Hospital on December 8th,
twenty-one days after the operation. He was in bed, calm, clear-
minded, and in good general condition. No convulsions had occurred.
The upper facial muscles act equally well on both sides, except that the
left eye cannot be closed independently of the right. In repose, the lower
part of the face appears nearly normal. The right lips are weaker and
• xpressive than the left, the right nasolabial crease has reappeared,
and is nearly equal to the left. In speaking or showing teeth, or form-
ing lips to make o sound, the inactivity of the right lips becomes evident.
The tongue protrudes almost perfectly straight, going a trifle to the right.
In smiling, both sides of the face act equally well. There is no drooling.
The left pupil is a trifle larger than the right; both active. Optic
nerves and retinal vessels normal.

Upper extremities. — No tremor in extension. The small muscles of
the right hand still show some atrophy, though, perhaps, less than at
note. Grasp on dynamometer : right, 22° and 25° ; left, 30° and
30°. Coordination is practically perfect. Unbuttoning and button-
ing shirt with right fingers alone, is successfully done, though slowly,
and a little awkwardly. All voluntary movements are well and quickly
made with right foot, coordination (heel-on-patella test) normal. Tho-
racic and abdominal muscles act well. Circumference of right calf 32
centimetres (12* inches), of left 31 centimetres (12 inches). No wrist
reflex. Knee-jerk high, but equal on two sides. The same is true of
the plantar reflex.

Sensibility. — On the face a light touch with finger is equally well felt

34 WEIR, SEGUIN, CEREBRAL LOCALIZATION.

on both sides, except that on the lips sensation is, perhaps, more acute on
the left side. The points of the aesthesiometer are distinguished on the
left cheek and chin at 10 ram., on the right side at from 10 to 15 mm.
The greatest difference exists on the upper lip, above moustache. On
red surface of lips points are separately recognized as follows : left upper
lip, 6 to 8 mm. ; right upper lip, 10 to 18 mm. Left lower lip at 4 mm. ;
right lower lip, 8 to 10 mm. On the tongue, average on the left side,
3 mm. ; on the right side, 4 to 5 mm. The patient claims to taste his
food properly on both sides of the tongue. Pricking is equally felt on
both sides of the face.

Upper extremity. — To light contact there is slight dulness of sensi-
bility on the right hand and forearm, but impressions are correctly
localized. iEsthesiometer points are distinguished at between 3 and 4 mm.
on pulps of fingers of both hands ; a little closer on the left side. Prick-
ing is more acutely felt on the left fingers, hand, and forearm, than on
the right. Appreciates heat and cold quickly on right hand. Muscular
sense tested with eyes closed. Can maintain right arm in extended posi-
tion several minutes. Passive movements are quickly and correctly
appreciated. Distinguishes small differences in weight in right hand,
and recognizes that two silver half dollars, laid one after the other on
the right palm are of the same weight. Sensibility of feet and legs
normal. Speech is slightly thick, and patient occasionally hesitates for
the word ; cannot utter it quickly.

Dec. 10. At about 10 a. m. had a convulsive attack. He rang for
the nurse, and told her a fit was coming on. She reports that his face
was then twitching on the right side, about the nose and beneath the
eye ; the right forearm was convulsed. Then he became unconscious,
and had a general convulsion, the movements being more marked on the
right side. Both pupils were dilated and equal; there was internal
strabismus of the left eye, and the head was turned to the left. The
convulsion lasted about one and a half minutes, and there was a short
subsequent coma; pulse 120, but no rise of temperature.

11th. Seems as well as before attack, except some mental depression.

16th. Allowed to walk a little. At 8.15 p. m. had another convulsion.

17th. One month after operation is allowed to go home, in good general
condition, and unquestionably better as regards paresis of face and hand.

On the 21st Dr. Godfrey had the kindness to send me the following
report : " Mr. B. arrived at 1 2.45 p. m. I saw him at 1 .30 p. m., and found
him feeliug very comfortable after his journey. Pulse 72 ; temp. 98.4° ;
resp. 17. I ordered for him the medicine as you directed (this was a
solution the dose of which consisted of Fowler's solution, n^v ; iodide of
potassium, 15 grains; bromide of potassium, 22 grains; water, jjij; to
be taken, largely diluted, on waking, after dinner, and after supper). I
have ordered him to be kept very quiet for a time, and his wife carries
out this instruction very well. He had a slight attack of epileptiform
convulsion yesterday, but it was very quickly controlled by the aniyl
nitrite. His wife says that since returning home he has been more
quiet, and his mind more at ease than when in the hospital. The amount
of power exhibited in kit right hand and (inn it <i complete surprise to >n<\
tma his speech is better than I have known if in n long time."

On Jan. 23, 1888, Mr. B. came to New York to see Dr. Weir and DM
at my office. He walked in as erect and active as any one, and passed
through a trying examination fairly well. Mental action is good, speech

WEIR, SEGUIN, CEREBRAL LOCALIZATION. 35

a little slow, but not aphasic (seldom pauses for the word). Has had
no marked attack in two weeks ; only an occasional twitching of the
facial muscles. Has also had a few vertiginous or faint feelings.

The pupils are equal and normal The upper facial muscles (naturally
weak) act fairly well on both sides, less on right. The mouth shows
some deviation to the left in repose. In showing teeth, paresis of
right cheek and lips becomes evident. In laughing both sides act
equally. There is no drooling. On the whole, the face is rather ex-
pressionless, somewhat like that of paralysis agitans. The right upper
extremity is paretic ; grasp, R. 26° and 26° ; L. 35° and 33°. Move-
ments of lower extremity normal.

Sensibility. — To light touch of end of pencil there is no difference
between the two sides of the forehead, ears, and neck. On the rest of
the face there is a distinct dulness of perception on the right side. The
sesthesiometer test shows no difference on the forehead. On the cheeks,
around mouth, and on chin, the points are distinguished at greater inter-
vals on the right side ; a difference of 50 and 75 per cent, in places.
Light touch is less well felt on the right than on the left hand, and the
dulness is most marked on the ends of the thumbs and fingers ; dorsum
and palm equally sensitive. The sesthesiometer, however, reveals no anaes-
thesia. Sensibility to passive movements and judgments of weight
(loaded rubber balls) unimpaired. On February 29th Dr. Godfrey wrote
at length about the patient's condition ; the following being essential
points. No attacks of any sort occurred from Jan. 9th to Feb. 25th
(forty-five days), when, after a chill in the night, he had a spasm " mostly
limited to the right side," at 8 a. m., followed by paresis of the hand.
Since, symptoms of severe remittent fever (pyrexia, jaundice, pain and
tenderness over liver, occasional chills) have been present, and have been
treated with quinine and calomel, the bromide being continued.

March S. I went to Bridgeport and examined Mr. B. with Dr. Godfrey.
The actual objective symptoms of cerebral disease are as at last note, but
the patient is generally very feeble, shows some jaundice, and a little
fever. There is much more aphasia than at any time ; so much as to
render tests of sensibility unreliable. I am of the opinion that this is
temporary, and only dependent upon asthenia. From 40 to 60 grains of
bromide of sodium to be given, besides the necessary general treatment.

March 19. During an exacerbation of fever there occurred a convul-
sive attack in the right hand. A similar spasm on the 25th. On the
26th a seizure (well described by his wife) occurred, consisting of only a
few clonic flexion movements of the right thumb.

April 3. I again visited the patient, and noted his condition as fol-
lows : Mr. B. is calm, clear-minded, and cheerful. Articulation is
slightly defective, phonation normal, he occasionally hesitates for a word ;
in answer to questions, he states that he knows the word he wants, but
cannot utter it. The jaundice has almost disappeared ; the tongue is
clean, appetite fair, axillary temperature 99°, pulse of good strength,
about 90.

Examination. — Face in repose rather expressionless, which I think
is normal. Right lower face less expressive than left. Pupils of medium
size, active, the left a little larger. Vision not tested, and fundus not
examined. In smiling and laughing (which the patient does heartily at
a medical story) both sides of the face act well. The right eye cannot
be voluntarily closed alone, whereas the left can. In volitional effort

WEIR, SEGUIN, CEREBRAL LOCALIZATION.

almost complete inactivity of the right lower facial and buccal muscles.
The tongue protrudes almost straight (a trifle to the right). All move-
ments of upper extremities are well and quickly done. The grasp is :
R. 11° and 11° ; left 21° and 25°. In extension the left fingers exhibit
some tremor. The interossei of the right hand are somewhat atrophied.
Movements of the leg not tested (patient in bed), but his wife states that
he steps well with both legs.

Sensibility. — Face not tested. Declares most positively (to repeated
questions) that the right hand no longer feels "numb." Feels the lightest
touch on right fingers and hand, and with eyes closed he distinguishes
consecutive contacts with coarse bed-cover, thin handkerchief, and a sheet
of paper. iEsthesiometer points are differentiated at about three milli-
metres on left finger-tips, and at four on right finger-tips. Feels tem-
perature equally well on both hands (and fingers). Muscular sense :
with eyes closed, recognizes such objects as a key, a knife, and a piece
of money placed in his right hand. A twenty-dollar gold piece being
placed in it, he calls it a dollar; a half-dollar he calls a quarter, but be
recognizes the difference between the weight of a half-dollar and that
of a quarter-dollar. With rubber balls loaded to a difference of half
an ounce up to four ounces, he recognizes differences quickly.

Mrs. B. states that since the return home convulsive movements have
not appeared in the cheek.

Fig. 5.

^<7^^/_

Reproduction of Mr. B.'g writing April 4, 1888, showing agraphic as well as simple motor defects.
(The patient never wrote a very good hand, and was not a good ipelter.)

On April 4th Dr. Godfrey made some tests of the patient's ability to
write, fhe few short attempts made caused great fatigue. By simple
dictation next to no result was obtained. A copy of the opening para-
graph of the Declaration of Independence was placed before the patient

WEIR, SEGUI.V, CEREBRAL LOCALIZATION. 37

ami was partly copied, partly written by dictation, with the copy before
him. The result, represented on page 36, shows faults due to the lack
of strength and coordination, but also distinctly agraphic faults. There

I alexia.

It thus appears that nearly five months after the removal of Mr. B.'s
cerebral tumor there is no very positive evidence of recurrence of the
growth. The increased aphasia and agraphia may possibly indicate the
invasion of more cerebral tissue by sarcomatous cells ; but this is not so
certain, because the aphasia has greatly diminished from March 8th,
and it is impossible to determine how much the remaining debility, due
to the remittent fever, may be resposible for symptoms now present.

It is greatly to be regretted that the normal course of the case should
have been so obscured and modified by an intercurrent disease.

Post-scriptum. — June 6th. Mr. B. goes to Europe for a stay of two
or three months. He comes to my office alone, and is himself attending
to the details of the voyage. General health has greatly improved ; is
stout and florid. Attacks as follows, since last note : April 24th, slight
clonic spasm in right hand ; 28th, had a convulsion, beginning by local
spasm in hand as usual, no biting of tongue ; 30th, twitching of right
thumb. May 14th, subjective spasm in right cheek and tongue, speech
suspended for a few minutes ; attack witnessed by wife, who says there
was no visible spasm or impairment of consciousness ; 26th, jerking of
right thumb for a few moments. No return of fever; only occasional
slight headache ; all functions normal. Speech has varied in freedom
from day to day.

Examination. — Apparently in perfect health ; pulse 84. Speech a
little slow, pauses for a word occasionally, but usually finds it. No head-
ache to-day. Thinks that right hand has become weaker (which is an
error), and states that a wooden or dead feeling (not formication) is
present in fingers, most in medius, not in thumb, or palm, or in face.
Drools occasionally from right buccal angle. Paresis of right lips and
cheek, as at last note. The tongue is straight, but trembles and looks
somewhat shrivelled, as in some cases of dementia paralvtica. Grasp :
right hand, 19*°, 20°, 22° ; left hand, 33°, 25°, 28°. Coordination of
hand perfect. Stands perfectly well with eyes open and closed, on
one or both feet ; walk normal. Patellar reflex normal, and equal on
both sides ; no wrist reflex. Sensibility is normal to touch, tempera-
ture normal, pricking on finger-tips aud hands. JEsthesiometric limits
on pulps of right fingers, 3 mm. Can distinguish differences in weight
of only a few grains in right hand, and is fully conscious of all passive

movements. Vision = — ; optic nerves normal.
xx

Treatment — On May 9th was given (in place of simple bromide solu-
tion) a solution of hydrate of chloral 7.50 gm., sodium bromide 37.50.
gm., water 200 gm., each teaspoonful containing 3 grains of chloral and
12 grains of bromide of sodium. Dose, 2 teaspoonfuls on rising, 1 tea-
spoonful at midday, 1 h teaspoonfuls after evening meal ; equal to about

38 HICKS, SEPTIC ABSORPTION.

4.5 gm., or 67 grains of the anti-epileptic salts per diem. Also, more or
less regularly, a pill containing arsenious acid 0.001, podophyllin 0.004,
ext. belladonna 0.015, quin. sulph. 0.20, after each meal. This treat-
ment is to be continued faithfully while away. Is to avoid over-exer-
tion, excitement, and exposure to great heat.

ON THE INFLUENCE OF BODILY MOVEMENTS OVER
SEPTIC ABSORPTION.

By J. Braxton Hicks, M.D. Lond., F.R.S., F.R.C.P.,

OBgTKTBIC PHYSICIAN TO ST. MARY'S HOSPITAL, LONDON : CONSULTING OBSTETRIC PHYSICIAN TO
GUY'S H08PITAL ; PAST PRESIDENT OF OBSTETRICAL AND HUNTERIAN SOCIETIES, ETC.

It is well known that the act of respiration is composed of four
periods, namely, inspiration, expiration, and an interval between each,
called pauses. Ordinarily, the duration of the pauses is much shorter
than that of the other stages ; and of the pauses, that between expiration
and inspiration the shorter ; and of the respiratory acts the inspiratory
rather the shorter.

The inspiratory act increases the capacity of the thorax by increasing
its diameter — most apparent at its base — and also by depressing the
diaphragm, or, in other words, by obliterating, in a degree, its natural
upward convexity. This alteration of shape is effected by its own
muscular action, and by" the stretching effect produced by the increased
diameter of its circumferential attachments ; normally, these movements
are synchronous. When, then, by the act of inspiration the capacity of
the chest is increased, a tendency to vacuum exists, which is corrected
by two methods : 1st, by the ingress of air through the larynx ; 2d, by
the flow of blood through the various veins leading toward the heart ;
for, during inspiration, the normal support of these vessels, which exists
during the pause preceding, is lessened, and thus the external air-
pressure existing on the general vascular system immediately acts, and
corrects the lessened tension by pressing the blood heartward. Thus,
in the respiratory act we have a force of considerable influence supple-
menting the heart-action.

But there is another part of the body which it is also necessary to
consider before we can fully apply these facts to the elucidation of our
subject. When the diaphragm descends it presses on the contents of the
abdomen, and these being more or less plastic, obeying the laws of
elastic fluids, press correspondingly in all directions. And although
the increased diameter of the base of the chest, to which the walls of

HICKS, SEPTIC ABSORPTION. 39

the abdomen are attached, would tend to increase the capacity of the
abdomen at the upper part, and thus lessen the pressure within tin
abdomen, yet there is a marked residuum of pressure during each inspi-
ration. This can readily be registered if we employ an apparatus
similar to the cardiograph tied tightly to the abdomen, which may be
called a gastrograph. The index will show a line wavelike as in the
tracings (Fig. 1 ). The relative duration of inspiration, pause, expira-
tion, and pause is well indicated.

Fm. 1.

Ordinary respiratory wave of the abdomen.

I have, hitherto, been speaking of normal respiration, If, however,
a sudden inspiratory movement takes place, voluntary or otherwise,
before the depression of the diaphragm can occur, then, instead of there
being a residuum pressure in the abdomen, there is a tendency to a
vacuum. Again, if, by voluntary effort, or by any restraint, the ribs are
unable to rise — in other words, the base of the thorax cannot expand —
then there is an increase of the pressure when the diaphragm descends ;
the usual condition resulting from tight-lacing, or the use of the belt.

If the effect of sudden inspiration be to produce a vacuum within the
abdomen, as it does within the thorax, then its importance, as a possi-
ble source of danger, must be self-evident to any one who has studied
medicine.

Xo doubt the elasticity of the abdominal walls and their yielding
nature materially minimize the effects of the thoracic vacuum, yet it
can readily be shown that it is not completely reduced, and, under some
conditions, scarcely at all.

Let me call the attention of the reader to the copies of tracings made
under various conditions from the gastrograph.

HICKS, SEPTIC ABSORPTION.

In Fig. 2 will be perceived the effects of coughing, laughing, etc.
The higher lines show temporary increase of pressure from within ;
while the lower indicate an increase from without ; in other words, the

Fio. 2.

llf

Arm \

|§

Cough

'/K

j^-^

/\n-

^ Laugh

Laugh

The effects of movements of the arm and of coughing aud laughing on the respiratory wave of the

abdomen.

tendency to vacuum. Referring, then, to Fig. 2, a rising and falling of
the line will be noticed on the ordinary movements of the legs, arms, or
trunk. This was from a person lying on his back. But the same effect.

Fia. 3.

The effect of movements of the legs upon the respiratory wave of the abdomen.

though in varying degrees, is found to follow all the movements of the
body, the more markedly the more suddenly they are done, whether of
the legs, arms, head, or trunk (Fig. 3). It is. doubtless, produced by

HICKS, SEPTIC ABSORPTION. 41

the sudden inspiration taken in order to fix the thorax preparatory to
the action of the various muscles attached to its various parts, especially
the abdominal muscles, which assist in fixing the thorax and consoli-
dating the firmness of the trunk.

It has long been believed that there is a tendency, under certain
conditions, to the existence of an insuck or indraw in connection with
the inspiratory act, but I think I have now given demonstrable proof of
the existence of a momentary excess of both pressure and vacuum within
both chest and abdomen.

Let us for a few moments glance at the effect of such a vacuum.

For the reasons above given there is a corresponding sudden rush
toward the chest in the veins principally; and doubtless also in the
lymphatics; at the same time the outward current in the arteries would
by the same force be checked. An opportunity would thus be given for
the dislodgement of any clots which might have been formed in the
veins. So also in the case of wounds a facility is given for any unhealthy
material to be drawn into the current through the severed ends of veins
or lymphatics, such as a portion of the plug, which might be purulent
or ichorous. Doubtless in conditions of perfect health these accidents
would generally be guarded against by the firmness of the plugs, and
the absence of irritating matter, but in a wound in an unhealthy state,
contrary conditions are present favoring the translation of portions of
unhealthy plugs or of septic matter in a more fluid state. And if we
admit the possibility of these things occurring, how much more are they
likely to take place in the puerperal woman, or in other similar condi-
tions, where every facility is given for the formation and increase of sepsis
in consequence of the retention of sanious fluids at a high temperature
scantily supplied with air ; and where easy opportunity exists for its
absorption through recently divided vessels of large calibre. Indeed, in
practice I have, I think, had sufficient evidence to prove that vigorous
movements of the pue^perium have been important factors in initiating
attacks of septic fever, and of renewing them during their subsidence.
Unless I am much mistaken, the renewal of the attacks of rigors, fever,
and sweating, has been produced by such movements. At any rate, I
have known cases where these attacks have followed each time the patient
had been much moved — I mean by getting out of bed, sitting up, or
changing room. So much has this impressed me by frequent occurrence,
that on seeing patients in consultation, with an account of renewals of
shiverings, etc., I have made special inquiries, and found very frequently
that these have followed those disturbances.

But if these conclusions are correct, another question will present
itself to us. May we not, in manipulating the uterus freely charged with
unhealthy fluids within, be favoring unwittingly septic infection, espe-
cially if the patient has been already under its influence? That this is

42 HICKS, SEPTIC ABSOKPTION.

probable seems to be borne out by the fact that I have observed in many-
cases where I have been obliged, in consequence of hemorrhage or fever,
to remove from the interior of the uterus retained portions of placenta
and firm clots ; indeed, I look forward to a slight increase of fever after
these manipulations. The sudden removal of the hand after firmly
pressing in the abdominal walls might, it appears to me, somewhat favor
an indrawing.

There is another circumstance in the puerperal state which can also
favor septic absorption from the inner surface of the uterus ; namely,
the sudden turning on the side from the back. At this time the walls of
the abdomen are very often relaxed and flabby ; so that when the patient
rolls over on her side, the abdomen and uterus fall over in a marked
degree if unsupported ; and thus there is a tendency to a vacuum deter-
mining a flow toward the abdominal cavity. If any one doubts this
tendency, he has only to place a woman with relaxed parts and flaccid
abdominal walls in the knee-elbow posture and open the vulva with
two fingers, and he will at once perceive that the inrush of air is very
marked. We take advantage of this fact in our attempts to restore the
retroflected pregnant or heavy uterus.

But the principle which underlies these facts does not belong only to
the puerperium, but to all cases under like conditions in abdominal and
gynecological surgery. It is not needful for me to indicate to surgeons
the importance of the above considerations as bearing on the surgery of
the chest, but I may be allowed to repeat that rapid movements, even
of, apparently only, the legs, produce a quick result on the capacity of
the chest.

It is difficult to gauge the practical importance of these considerations.
As above remarked, the conservative forces of perfect health neutralize
much of the effects of sharp movements, but in opposite states it appears
to me that we should permit the patient to assist him or herself as little
as possible in those conditions where the kind of injury facilitates septic
absorption, or in cases of venous inflammation with plugging. The
importance of this caution was sadly illustrated in the case of one who
was my fellow-student. He was very athletic, and had, at the age of
forty, from over-exercise, inflammation of one of the veins of his leg.
He had lain quiet for some days, when, suddenly turning in bed, he
felt that something had flown from his leg to his heart ; he expressed a
fear that he would be dead in a few days which was the case. Symptoms
of blocking of the pulmonary arteries soon came on.

Theoretically, I suppose, we may say that by mechanically checking
or restraining the elevation of the ribs and abdomen by a bandage we,
in a very considerable degree, lessen the risk attending rapid and sudden
movements. But my object in this communication is rather to demon-

JOHNSTON, ULCER OF THE DUODENUM. 43

strate the effect of bodily movements, leaving it to your readers to
i in prove upon my remarks.

There are other interesting points in connection with this subject, for
an exposition of which I may refer the reader to the Proceedings of the
M Urnl Society of London, 1883, " On the Tension in the Abdomen," and
to " Notes," Royal Society's Proceedings, " On the Supplementary Forces
Concerned in the Abdominal Circulation in Man," March 25, 1879.

I should add that where the abdomen is distended the effect of inspira-
tion or bodily movements to produce a vacuum is necessarily lessened.

SIMPLE ULCER OF THE DUODENUM.

ROUND PERFORATING ULCER OF THE DUODENUM, WITH THE
HISTORY OF A CASE.1

By W. W. Johnston, M.D.,

OF WASHINGTON, D. C.

BlMPLB, round, or perforating ulcer of the duodenum is of the same
nature as the round, perforating ulcer of the stomach, but while the
pathological anatomy and symptomatology of gastric ulcer have long
been fully known, duodenal ulcer has still an undetermined place in
medical pathology.

Gastric ulcer was first anatomically described by Mathew Baillie in
1793, and the symptoms recognized by John Abercrombie in 1824, but
to Cruveilhier is due the credit of having first given a full and accurate
description of the disease in its anatomical and clinical details, in his
great work published in 1830. In 1839 Rokitansky made seventy-nine
cases the basis for a very elaborate study of the disease, and since that
date but few material additions have been made to our knowledge of the
and its symptoms.

Duodenal ulcer has a much more recent history ; the first* undoubted
example which I have been able to find, was reported in 1828 (Robert,
Bull. Soc. Anat. de Paris, 1828, iii. p. 171) ; the description of the lesion
in this case is strictly accurate. The patient, a youth, aged seventeen
re, suffered for several months with vague pains in the epigastric
ton; after this he had nausea, loss of appetite, and general malaise.
Perforation of the ulcer took place after a full meal, and death resulted
from subacute peritonitis. At the origin of the duodenum, immediately
below the pylorus, was an oval ulcer, three to four lines in diameter, the

1 Read before the Medical Society of the District of Columbia.

* Teillais alluded to an observation of duodenal ulcer, in a thesis of 1824, but I have not been able to
find it.

44 JOHNSTON, ULCER OF THE DUODENUM.

edges of which were smooth, rounded, having a punched-out appearance,
and darkish gray in color. The bottom of the ulcer was formed of the
peritoneal coat of the intestine, with a perforation, a line in diameter, in
its centre. Near this ulcer was another involving the mucosa only.

Scattering observations were published in the following years, among
which was one by John Abercrombie (Edin. Med. and Surg. Jovrn.,
1835, vol. 44, p. 278), to whom so much is due for the early knowledge
of gastric ulcer. Klinger, of Wiirzburg, collected ten cases in 1861, and
added three of his own ; the disease was not recognized during life in
twelve of the thirteen cases. In 1863 Trier published a number of cases
and added twenty-six which he had seen in the hospitals in Copenhagen
from 1842 to 1862. Krauss, in 1865, reviewed eighty cases, and in the
same year Morot, in his graduation thesis (Paris), described and com-
mented on twenty-two cases, which included several due to burns. Four
years later, in 1869, Teillais, in his graduation thesis (Paris), gave a full
review of the lesion and its symptoms as illustrated in sixteen carefully
recorded cases. Chovostek, in 1880, made an addition of 63 new cases to
80 before reported, making 143 in all. Since this date a number of cases
have been added to this list. In the Index Catalogue of the Library
of the Surgeon- General' a Office, 123 authors have reported one or more
cases of simple ulcer (not including those due to burns and scalds) ; the
earliest of these was in 1828, the latest in 1881. Since this date the
number has been still more extended. In March, 1887, Osier reported
nine cases, with autopsies {Canada Medical and Surgical Journal), to
which he added commentaries.

In April, 1887, Bucquoy published a comprehensive article, reviewing
the state of opinion as to the diagnosis of the disease, and formulating
new and more precise rules, basing his conclusions upon the observation
of five cases, four of which recovered. The paper is a valuable contri-
bution, as it gives a new working basis, a thesis to support or reject, by
further study and comparison of symptoms and lesions. During the
past year there have been several cases added to the record, all of them
with autopsies, which afford fresh illustrations of our present knowledge.
But no complete and accurate collection of cases has yet been made.
All doubtful cases which have not the anatomical peculiarities of a
simple peptic tumor should be excluded from this list, whenever such a
complete collection is made.1

The history of a case which I have now under observation, affords an
opportune text for reviewing the subject in its new phase; it bafl pre-
sented all of the symptoms which Bucquoy thinks are characteristic of
duodenal ulcer.

1 The first case given in the bibliography of chiudeiml ulcer, in the article in Klsia—ll'l < 'vclnpnMin,
i» not am of mud nicer, i>nt of ■ perforation of the wall of the tnteatlna by an abaosai of the liver.

JOHNSTON, ULCER OF THE DUODENUM. 45

Duodenal ulcer is much less common than gastric ulcer ; the propor-
tions are as 1 to 30. Ulcer of the stomach is found in 1 to 2 per cent,
of deaths from all causes ; it is a common lesion, Trier found 261 cases
of gastric to 28 of duodenal ulcer, and Willigk, in autopsies made in
hospitals in Prague, found the stomach affected 225 times, while in 6
cases only was the lesion in the duodenum. In Hughes Bennett's cases,
selected for their interest or variety, there are four of gastric and one of
duodenal ulcer. Osier found 9 cases of the intestinal variety in 1000
Autopsies.

>gy. — Duodenal ulcer is most common between thirty and forty
years; gastric ulcer between twenty and thirty. After sixty years both
diseases are rare. Ulcer in the duodenum has been found at six, eight,
nine, and fourteen years, but is very rare in early life. C. R. Woods
saw one in an infant immediately after birth (Med. Press and Circular,
1878, N. S., xxv., 1888).

Sex exerts an opposite influence in the two diseases. Out of Krauss's
64 cases of ulcer in the duodenum, 58 were in men, a percentage of
96s, while of those who had gastric ulcer 60 per cent, were women.
Chlorosis and anaemia are mentioned as having a decided effect in pro-
ducing it.

Occupation and station in life have an influence in the case of the
stomach ulcer ; the poor are more affected by it ; it is met with in needle
women, maid servants, and female cooks. In the case of the intestine
no such predisposition exists.

Ulcer of the duodenum occurs in connection with certain constitutional
states, and from other causes which do not seem to have any effect in
bringing about the same disease in the stomach, as septicaemia, erysipelas,
waxy degeneration of the abdominal viscera, long-continued abuse of
alcohol, suppression of hemorrhoidal discharges, cardiac and pulmonary
diseases.

The frequent occurrence of duodenal ulcer after burns or scalds of
the skin, and more rarely after frostbite, has been frequently noted ;
the ulcers, however, which occur in this association ought not to be
classed with those which are more chronic in their course and which
have no evidence of inflammatory action about them.

Many of the cases which have been recorded have occurred in men
who have been in apparent health, or who have had no symptoms beyond
those of indigestion.

Pathogenesis. — The fact that the round ulcer is found in the beginning
of the duodenum, above the point where acid reaction is changed to
alkaline reaction by contact with the bile and pancreatic juice, goes to
show that the genesis of duodenal ulcer is the same as that of gastric
ulcer. The primary change in the tissue is a vascular disturbance due
to a variety of causes, as chronic congestion from hepatic disease, acute

TOL. 96. SO. 1.— JCLT, 1888. 4

46 JOHNSTON, ULCER OF THE DUODENUM.

and chronic intestinal catarrh from any cause, or spasmodic contraction
of the muscular wall of the intestine. Ansemia and feeble circulation
may also be causes. Irritating ingesta and external injuries1 may have
the same effect as in gastric ulcer. As a result of such conditions of
circulatory disturbance an arrest of circulation may take place in a
limited area from embolism or thrombosis. A portion of the wall of the
gut becomes deprived of nutrition, dies, and is acted on by acid corro-
sion. The ulcer is a peptic ulcer, the result of a process of digestion or
solution of necrosed tissue.

The pathological anatomy of ulcer in the duodenum does not need
much description in a paper of limited scope. The ulcer is found in the
majority of cases in the horizontal portion of the intestine, on its anterior
wall near the pylorus, that is, well above the opening of the bile and
pancreatic ducts. There is usually only one, sometimes several ulcers.
Occasionally ulcers are found in the intestine and stomach at the same
time (J. Finlayson, Glasgow Med. Journal, Oct. 1887), and in one case an
ulcer extended the same distance on each side of the pyloric ring. In
shape the ulcer is round, infundibuliform and terraced, without any
evidence of inflammatory action at its periphery. If a perforation has
occurred, the small pin-head opening is at the bottom of the ulcer, and
peritonitis has resulted. Adhesion with neighboring organs may prevent
perforation and in rare cases inter-intestinal or gastro-intestinal fistuhe
have resulted from perforations, connecting one viscus with another after
the formation of adhesions.

If cicatrization sets up in an ulcer, in time a scar only is left to mark
its place, and sometimes the contraction of cicatricial tissue may lead to
a narrowing of the pyloric orifice, and to dilatation of the stomach, or
to irregular dilatation of the intestine ; the bile duct or pancreatic duct
openings may be closed in the same way.

The symptomatology of the disease is well illustrated by the following
history of my case :

Mr. X., a;t. forty, without any special hereditary predisposition and of
good health in early life, began to complain of symptoms of indigestion
about twelve or fifteen years ago. His life was usually a sedentary one,
although he would periodically indulge in active exercise in outdoor
sports. He was a robust, healthy man, weighing 175 pounds, with a
ruddy complexion. The symptom of which he complained most during
this long period, and which he always regarded as due to indigestion,
was a pain, sometimes severe in character, seated in the right hypoehon-
drium, at and below the lower border of the liver.

In 1881 he began to be much depressed in spirits, brooded over his

1 The influence of hot ingesta in producing gastric ulcer lias been experimentally demonstrated in
dogs by Decker (Fortschritte der Med., B. v. 415). The effect of trauma has also been studied experi-
mentally by Bittio. A Mow on the stom;icli of an animal caused hemorrhagic infiltration between the
mucous membrane and the tissue below ; tho gastric juice would have soon converted this area into an
i>1.-. r (Zeitscta. f. kl. Med., It. \ii. 11. r. tad t;. 598).

JOHNSTON, ULCER OF THE DUODENUM. 47

suffering and indigestion, and during two years made no improvement.
At the end of this time he felt better until 1887. In the last week in
March, 1887, he went on a hunting expedition and ate very indigestible
food for some days. The pain in the side grew worse, and was espe-
cially so on his return home. In April this pain became distinctly
localized at the lower edge of the liver in the right hypochondrium ; it
always came on three hours after eating, and lasted one hour or longer.
It was accompanied by a sense of oppression, and he was always very
much depressed in spirits at these times. There was never any symptom
of gastric indigestion, and no constipation or diarrhoea.

He describes the history and character of the pain in the following
words : " After months of health there would be some slight symptom of
indigestion, as heartburn or a sudden feeling of nausea, accompanied by
a copious flowT of saliva lasting a few minutes. This sudden nausea and
swallowing of saliva would occur only once or twice at the beginning of
the disorder. But this symptom has been present at the beginning of
so many attacks, that I came to consider it the forerunner of the pain
in the right side. A few days or more after this the uneasiness in the
right side would commence, followed by more or less pain for several
weeks, until relieved by medicine or diet, or by the attack wearing off."

During April, and especially after the 12th, the pain was worse than
it had ever been before, the paroxysms being most intense at eleven to
twelve in the morning (three hours after breakfast), and in the after-
noon (about three hours after dinner), but not ceasing until late in the
night. The pain was at its maximum for an hour after its onset, then
lessened, but did not disappear for several hours later.

On April 29th he noticed that his movements were black (he had
two on this day), but they were otherwise normal in appearance. Later
in the day he felt weak, but spent the evening with some friends, who
remarked that he did not look well. At bedtime his legs seemed very
feeble, and he had a profuse perspiration. April 30th, in the morning
had another black stool, semi-solid and large, and afterwards he was so
weak that he remained in bed and took only a milk diet. At 11 p.m.
he became suddenly collapsed and partly unconscious ; collapse being
due, as subsequent events proved, to intestinal hemorrhage. Soon after
he had an involuntary discharge of a large quantity of blood, with some
dark tarry matter from the bowel. Stimulants were given and he
revived somewhat ; half an hour later he had another copious stool of
the same nature. Aromatic spirits of ammonia and ergot internallv,
and numerous hypodermatic injections of whiskey were given by Dr.
Franzoni, who had been summoned hastily. Dr. Franzoni states that
the collapse was accompanied by fainting attacks, and that he seemed
alarmingly ill when he arrived.

When I saw him, one hour later, he was still in a state of partial
collapse, pulseless, and cold. Ice was applied to the abdomen and
hypodermatic injections of ergot and whiskey were continued. Later,
acetate of lead and opium were given by the mouth in full doses, and
iced Valentine's beef juice was the first nourishment allowed him. Very
gradually, the patient came out of the condition of collapse, but re-
mained very feeble for eight or ten days. By April 5th he was much
stronger and slowly convalesced. The bowels were not moved for ten
days, and no further hemorrhage occurred. From thi3 time he was
kept on liquid diet for some week, but as the pain did not reappear he

48 JOHNSTON, ULCER OF THE DUODENUM.

was then allowed to return to solid food. From that time, April, 1887,
up to within three weeks, there had been no symptom to indicate the
existence of any disease in the intestine, but since the early part of this
month there has been occasional pain after eating, and for a week past
severe pain as before, about three hours after each meal. He is now
taking nothing but milk.

The more characteristic symptoms, as exemplified in this case, are
the occurrence of pain of a severe character three to four hours after
eating, situated in the right hypochondrium, below the lower border of
the liver and to the right of the median line, that is, over the duodenal
region. There is also increased sensibility to pressure over the same
area. The stomach digestion is in perfect order ; there is no eructation
of gas or fluid, no heartburn, aud the appetite is good and the tongue
clean. Sometimes vomiting occurs, often when the pain is at its height.
Under appropriate treatment such a case may go on to recovery ; but
usually, sooner or later, hemorrhage occurs from the extension of the
ulcer ; if small in amount, and recurring, the patient becomes anaemic
without apparent reason ; if a larger amount of blood escapes into the
bowel, the stools are black and viscid. The amount of hemorrhage
determines the extent of collapse and of the acute ansemia. If, as in
the case reported, the amount is great, the patient may be in imminent
danger, or may die. If, however, he escapes with life, he is by no
means out of danger. Perforation and peritonitis may occur at any
subsequent time and death is the result.

Under favorable conditions cicatrization begins, and the patient may
recover. The duration of the disease is said to be from three to five
years ; the rapidity of the process of healing depending upon the treat-
ment pursued. Acute ulcers, as from burns, heal quite rapidly. Cica-
trization has been seen to begin on the tenth day after a burn ; in
another case it was completed at the eighth week. Mr. Holmes saw a
case where it was finished in twenty-eight days. But chronic round
ulcers heal slowly, alternating between extension and repair, and are
accompanied by a corresponding fluctuation in the symptoms.

The more positive symptoms have not the same relative value ami
frequency. Abdominal pain is not always present, and just in what pro-
portion of cases it is present cannot be stated ; it is seated either in the
epigastric region or right hypochondrium. A strict limitation of seat is
not of great importance ; the pyloric end of the stomach and the upper
inch of the duodenum are so near, that in many cases there could not
be a marked distinction of seat between the pain of a pyloric and
duodenal ulcer. The time of its appearance, however, is of more value ;
in duodenal ulcer it does not appear until, gastric digestion being
ended, the acid chyme passes through the pylorus and enters the intes-
tine. Pain, therefore, which begins at a late period, in two or four hours

JOHNSTON, ULCER OF THE DUODENUM. 49

after a meal, is more probably of intestinal origin. This late occur-
rence of pain was noted in my case. The attacks of pain are frequently
intense, simulating the agonizing pains of biliary and renal colic. They
last from a few to many hours, are especially worse at night, often pre-
venting sleep. In one of Osier's cases (verified by an autopsy) the pain
was so severe that the patient could not sleep ; " he would frequently sit
on the edge of the bed for hours doubled up with pain." My patient's
present sufferings are so great that he has frequently required morphia
at night. Sometimes the pain is not limited, but radiates in the abdo-
men, and in other directions, or induces reflex neuralgias, convulsions,
dyspnoea, and suffocative attacks. In the case already referred to, the
patient described the pain as starting in the epigastric region and passing
to the back and round the sides. My patient now speaks of his pain as
extending from the right hypochondrium outward and backward in the
direction of the liver. He holds his hand over the outer portion of the
right lobe of the liver, as if the pain was greatest there.

lnk'stinnl hemorrhage is the symptom upon which most reliance can
be placed. It is more constant, and its peculiar character of thick tarry
matter shows that it comes from a point high up in the intestine. By
excluding hemorrhoids, chronic dysenteric ulceration, malignant and
tubercular disease, and the hemorrhagic diathesis, as causes, duodenal
ulcer may be recognized by this one symptom alone. Per contra, Trous-
seau (Clinique Mtdicale, vol. iii. p. 86) reports three cases which he saw
with collapse symptoms due to intestinal hemorrhage, the blood passed
having the character above mentioned. One of these terminated fatally ;
no lesion was found in the stomach or intestines.

Among the cases of duodenal ulcer with autopsies, reported during
the last year, hemorrhage was a common symptom. In a fatal case of
Wising and Wallis (Tr. Medical Society of Sweden, February 8, 1887,
pp. 71-74) hemorrhage preceded death ; two ulcers were found in the
duodenum and the intestine contained a large quantity of blood. Dr.
Rothmann described at the session on June 20th of the Society for
Internal Medicine of Berlin (Deutsch. med. Zeitung, Xo. 53, 1887) the
case of a patient who died from perforation of a round ulcer of the
duodenum. Two years before death, evacuations of dark blood appeared,
which were stopped by applications of ice, and sugar of lead internally.
They recurred, after a considerable time ceased, but returned in January,
1887. June 16th he was taken suddenly with the symptoms of perfo-
ration and died in twenty-four hours. Coats and Gairdner showed a
specimen of perforating ulcer of the duodenum to the Glasgow Patho-
logical and Chemical Society in March, 1887 (Glasgou- Med. Journ.,
October, 1887) ; hemorrhage had occurred during life. It was present
in four of Osier's cases, and was evidently the cause of death in two.

Vomiting of blood occurs in a certain proportion of cases.

50 JOHNSTON, ULCER OF THE DUODENUM.

But there are numerous cases in literature in which there were no
symptoms during life, or none so marked as to attract the patient's
attention, up to the moment of a dangerous or fatal hemorrhage; a per-
foration and rapidly developed peritonitis have often been the first signs
of the existence of any serious disease.

In other instances, the symptoms have been so unlike those which I
have mentioned as being typical, that they have been mistaken for
numerous other conditions which they simulated.

The following are examples of latent forms without symptoms, or with-
out typical symptoms. Bennett, in his Clinical Medicine, reports a case
in which death occurred from pulmonary and renal disease ; a post-
mortem examination revealed a duodenal ulcer which had perforated
the intestinal wall, peritonitis resulting. The ulcer had not been mani-
fested by any symptom whatever during life. Pepper and Griffith
record a fatal case of pulmonary tuberculosis (The American Journal
of the Medical Sciences, January, 1888), in the course of which
there had been evidences of dilatation of the stomach and fermentative
dyspepsia, but there were no symptoms pointing directly to the duod-
enum as the seat of disease ; a shallow ulcer was found near the pylorus,
and two or three feet lower down there were numerous other ulcers.
The absence of pain in this case is not so remarkable, as the ulcera-
tive process was not deep, and the patient was probably taking food in
small quantities and in liquid form for a long time before his death.
These authors refer to a case of death by perforation of a duodenal ulcer
and by the establishment of pyopneumothorax subphrenicus. The ulcer
"had existed for some time totally without symptoms" (Pusinelli,
Berlin, klin. Wochenschr., May, 1887, 312). Littlejohn presented at a
meeting of the Medico-Chirurgical Society in June, 1887, three specimens
of duodenal ulcer. The second case was one of fatal perforation of a
duodenal ulcer occurring in an intemperate soldier, who had been in
hospital in the Soudan with what was said to have been dysentery ; he
was not known to have any symptoms of this disease. The third speci-
men was from a patieut who died suddenly two days after his discharge
from the Royal Infirmary, where he had been treated for delirium
tremens. He had no symptoms of the fatal lesion, and had been dis-
missed as well. Urgent vomiting immediately preceded death. An
ulcer was found in the duodenum, but there was no perforation ; the
cause of death was not clear (Edinburgh Med. Joum., October, 1887).

As an example of the simulation of other diseases by duodenal ulcer
the following case may be given, as reported by A. Dutil ( Bulletin
AiKtl,, July 1, 1887): A man in perfect health was seized with violent
(•"lie two hours after eating; vomiting, tympanitic distention, constipation,
and almost entire suppression of urine followed, lie was ill eighteen
hours, and was supposed to he ■offering from internal strangulation. Ai

JOHNSTON, ULCER OF THE DUODENUM. 51

the autopsy a round ulcer with sharp-cut edges was found on the anterior
wall of the duodenum just below the pylorus, perforated at its base with
resulting peritonitis.

The symptoms due to ulcers of the duodenum and perforative perito-
nitis have been mistaken for lead colic, hepatic and renal colic, poison-
ing, internal strangulation or strangulated hernia. A. Clark reported
two cases which were mistaken for cholera, and isolated. The diag-
nosis of gastric ulcer has frequently been made in cases where the
lesion was in the duodenum. And there can be very little doubt that
intestinal hemorrhage has often been referred to causes other than the
true one.

Diagnosis. — Is the diagnosis of duodenal ulcer possible, and can it be
differentiated from gastric ulcer? Wilson Fox (Reynolds's System of
'due) says that "the symptoms of duodenal ulcer differ but little
from those which are met with when the disease occurs in the stomach."
Osier (loc. cit., p. 461) believes that "the diagnosis of duodenal from
gastric ulcer is rarely possible, as there are no distinctive features. The
gastralgic attacks occurring at intervals for many years appear to be
more common in duodenal disease." Bucquoy, on the other hand, says
that " the diagnosis of simple ulcer of the duodenum is not impossible,
as is supposed, and, moreover, is distinguished by well-defined characters
from ulcer of the stomach, with which it is most often confounded."

Much of the confusion in diagnosis is due to the fact that observations
which are made the basis for conclusions are many of them imperfect.
In Osier's nine cases, for example, there are four with little or no ante-
cedent history. Patients are often not kept from work by the existence
of a duodenal ulcer, and they only apply for relief when there is exces-
sive hemorrhage or perforation. Moreover, there is a question whether
it is proper to class all forms of duodenal ulceration under this head.
Round, simple, or perforating ulcer of the duodenum is a specific lesion,
and unless the ulcer has a definite and characteristic appearance, the
case should be excluded from this, category. When the ulcer is large,
irregular, and is complicated with the existence of similar ulcers in the
intestinal canal lower down, it probably is not a true peptic, duodenal
ulcer. In Case I. of Osier's collection, the ulcer was three-quarters of an
inch in diameter, the edges overlapped ; he supposes it to have resulted
from the rupture of a cyst of Brunner's glands. There were also ulcers
in the caecum, ileum, and colon. In Case IV. an extensive ulcer of the
duodenum had nearly healed, with resulting stenosis. This may or may
not have been a peptic ulcer. Case II. was a case of phthisis with a
single ulcer in the duodenum, and with extensive ulceration of ileum,
caecum, and colon. In Case VI. there was an " irregular ulcer extending
around the greater part of the circumference of the gut and presenting
an imperfect division into two portions; " the edges were undermined.

52 JOHNSTON, ULCER OF THE DUODENUM.

I refer to these cases to show that some classed as examples of simple
ulcer of the duodenum, and upon which statistical conclusions are based,
do not properly belong to this class. Greater precision in classification
may lead to different conclusions as to our ability to distinguish duodenal
from gastric ulcer and from other lesions.

I have noticed, also, that the cases in which the more characteristic
symptoms have appeared, have been examples of uncomplicated simple
ulcer of the duodenum, when this was the primary lesion ; whereas,
latent cases, cases without symptoms or with atypical symptoms, have
been those in which the ulcer did not have the characteristic appearance
and was accompanied by lesions in the lungs, kidneys, and other organs,
and by chronic cachectic states. This was the case in Bennett's and
Pepper's cases, which have been quoted as examples of duodenal ulcer
without symptoms.

It seems to me probable that in time primary peptic ulcer of the
duodenum will be differentiated and be distinguished by its symptoms
from other ulcers in the same region.

In a certain number of cases, where the symptoms are latent, a diag-
nosis is impossible up to the moment of a profuse intestinal hemorrhage
or a fatal peritonitis. The character of the blood passed and the exclu-
sion of other sources of blood may justify a diagnosis from this symptom
alone.

Perforative peritonitis, from duodenal ulcer, occurring in a case
without previous history, cannot be traced to its true cause ; it may be
suspected from the location of the pain of onset.

Cases in which duodenal pain of chronic intermittent character is the
only symptom, may be mistaken for gastralgia or enteralgia, but this
condition is more common in women associated with uterine disease,
amemia, chlorosis, or malaria, or may be due to exposure to cold. It
bears no relation to food, and is not increased by pressure.

The pain of chronic intestinal indigestion is not severe, nor so circum-
scribed and is accompanied by borborygmi and occasional diarrhoea.
Acute intestinal colic or the passage of a biliary or renal calculus, may
be recognized by the causation, time of occurrence, seat, character of the
pain, and subsequent history. There are other lesions, as mesenteric or
visceral cancer (liver, pancreas, kidney), which might be attended with
pain in the same region, but the progress of the case, the growth of a
tumor, and emaciation would clear up this point.

A diagnosis of duodenal from gastric ulcer is possible, perhaps easily
made, if a sufficient number of symptoms are present.1

i Wilson Fox (Diseases of the Stomach, 1871) says: "Without the simultaneous occurrence of
the greater number of the symptoms the diagnosis of (gastric) ulcer must often remain somewhat
uncertain."

JOHNSTON, ULCER OF THE DUODENUM. 53

Gastric Ulcer. Duodenal Ulcer.

1. Most common in women from 1. Most common in men from thirty
twenty to thirty years of age. to forty years of age.

2. Pain in epigastrium soon after 2. Pain in right hypochondrium
eating. two to four hours after eating.

3. Pain relieved by vomiting. 3. Pain not relieved by vomiting.

4. Vomiting of mucus, bile, and 4. Vomiting rare; no gastric indi-
food — gastric indigestion. gestion.

5. Hseinatemesis common. 5. Haematemesis rare.

6. Hemorrhage from intestines 6. Hemorrhage from intestines
rare. common.

One would be justified in making a diagnosis of duodenal ulcer if a
man, otherwise in good health, between thirty and forty years of age,
suffers from attacks of severe pain below the edge of the liver to the
right of the median line, the pain coming on from two to four hours
after eating, lasting for from one to four hours, and gradually lessening,
to recur after the next meal, being most prolonged and most severe at
night. Such a symptom, without gastric indigestion or the evidence of
any organic lesion, pursuing a chronic course during a year or more,
with remissions and exacerbations, being benefited by liquid diet and
aggravated by indiscretions in diet, could reasonably be attributed to
duodenal ulcer as a cause. This diagnosis would be confirmed by the
occurrence of intestinal hemorrhage of the character described, or by
the sudden development of perforative peritonitis.

Prognosis. — An unfavorable termination has been thought to be the
rule, but this opinion was based on an imperfect knowledge of the dis-
ease ; it was frequently not recognized except at the autopsy ; only
fatal cases, as a rule, have been recorded. If a diagnosis could be made
early and a proper treatment patiently carried out, there is every reason
to think that the result would often be successful. Ulcers of the stomach
are known to heal in many instances. Out of 11,888 post-mortem ex-
aminations in Prague, there were found in 373, or 3.1 per cent., healed
gastric ulcers, and in 164, or 1.4 per cent., open ulcers. 85 to 90 per
cent, of all cases of gastric ulcer recover. It is reasonable to believe
that duodenal ulcer has as favorable a prospect of recovery as this: four
out of Bucquoy's five cases recovered.

tment. — The plan of treatment must be essentially the same as
that pursued in gastric ulcer. The cicatrization of the ulcer is hastened
by rest and absence of irritation, and delayed even by the necessary
functional activity of digestion. An exclusive milk diet kept up for a
long time is, therefore, first to be tried; and the milk can be made more
digestible and less irritating by the various means at our disposal.
When the palate tires of milk, other liquids can be given. In certain
cases feeding by the rectum may enable the patient to do without food

54 JOHNSTON, ULCER OF THE DUODENUM.

by the mouth almost altogether, and when hemorrhages occur frequently
or when the abdominal pain is increasing, such a course should be tried.
Pancreatin, pepsin, and other aids to digestion should be given by the
mouth if there are evidences of intestinal or gastric indigestion.

Food must be given and nutrition must be sustained, as the danger of
anzemia and emaciation is great. Iron, in a very soluble form or hypo-
dermatically, may be required. Quinke produced artificial gastric ulcer
in dogs and found that repair was rapid except in anaemic and debili-
tated animals. (Ziegler : Pathological Histology, vol. 2, p. 269, Wood's
Library edition.)

It is doubtful whether there is any remedy which favors cicatrization
of the ulcer by its local effect, unless it may be nitrate of silver in small
doses kept up for some time. The ordinary remedies for digestive dis-
turbances and constipation may be needed from time to time. In the
event of hemorrhage, ice to the abdomen, ice by the mouth, ergot and
morphia, subcutaneously if there is pain, with large doses of acetate
of lead or other styptics internally, are the remedies. If death is immi-
nent from excessive loss of blood transfusion would be demanded ; this
has been practised successfully in the hemorrhage of gastric ulcer. The
injection into the veins of a solution of common salt is believed to be
equally efficacious and without some of the dangers of blood transfusion.

If the symptoms should indicate perforation and beginning peritonitis,
there is but one course to be pursued, and that is to open the abdomen
and repair the rent, excising the ulcer so as to have only normal tissue
left. If this is suggested and approved of in the perforation of gastric
ulcer, and even of the intestinal ulcer of typhoid fever, it is entirely
applicable in duodenal perforation.

REVIEWS.

A Practical Treatise on Diseases of the Skin, for the Use of Stu-
dents and Practitioneks. Second edition, thoroughly revised and
enlarged. By James Nevins Hyde, A.M., M.D., Professor of Skin and
V.nereal Diseases, Rush Medical College, Chicago, etc. Pp. 676. Phila-
delphia : Lea Brothers & Co., 1888.

In the rive years which have passed since the publication of the first
edition of this book much and good work has been done in dermatology.
The number of its special students has largely increased, and their ob-
servations, published in the form of general treatises, monographs, papers
in journals, and reports of discussions in congresses and societies, have
so multiplied that it has become almost an impossibility, even for the
specialist, to keep one's self fully acquainted with the progress in this
department. A new edition of Professor Hyde's valuable treatise, repre-
senting, as it does, these latest advances in dermatology, is therefore very
welcome.

The whole work has been largely rewritten, and new matter to the
extent of one hundred pages has been added, devoted mostly to the
description of diseases recently isolated from affections with which they
have hitherto been confounded, to new and important views relating to
the etiology and pathology of others, and to the action of many new
remedies, all of which have received full and careful consideration.
Thirty additional woodcuts and two colored plates, illustrative of the
gross and microscopic appearances of diseases, have also been intro-
duced, which are generally excellent in quality. The greatest change
in form has been the rearrangement of diseases in accordance with the
plan of classification officially adopted by the American Dermatological
Association, which greatly adds to the value of the book for practitioner
and student, as this system is a simplification of Hebra's, and is more
generally in use in this country than any other.

It is not our intention to offer again a critical notice of the work,
although a few of the author's views challenge discussion :

It may be doubted if the conditions described under the title "eryth-
ema intertrigo" are rightly placed ; they might well be regarded as the
erythematous stage of eczema in most instances. We wish, too, that
the author had given fuller account of the various forms of erythema
multiforme.

In his chapter on lichen ruber sufficient attention has not been called
to the occurrence of the intense melanoderma which forms so striking a
feature in the last stages of most cases of this rare disease.

The possible etiological relations of the so-called verruca necrogenica
to cutaneous tuberculosis, which have been lately discussed by patholo-
gists, have received no mention.

56 REVIEWS.

In his directions for the employment of electrolysis in hypertrichosis,
which are given with the most satisfactory fulness of detail, the author
states that it is better to operate in succession upon contiguous hairs,
instead of selecting one here and one there, as the latter course is pro-
ductive of greater pain. The former method may, indeed, be less painful ,
but is in our judgment much more likely than the latter to result in
permanent scarring, in consequence of the greater inflammation produced
thereby.

In connection with the etiology of alopecia areata it seems to us that
somewhat insufficient consideration has been given to the evidence which
has been presented by eminent observers, bearing upon the question of
its sometime parasitic nature.

In his account of lupus erythematosus a more detailed description of
its appearances upon the hands, which Dr. Hyde is especially competent
to contribute, and upon the scalp, would have given it greater value.

The chapter on tuberculosis of the skin is unsatisfactory, in which
respect it unfortunately represents fairly enough our present knowledge
of an important field of cutaneous pathology.

With regard to the favorable influence of a residence in the United
States upon the course of leprosy in the individual, we are not prepared
to admit the optimistic views of the author, although there can be no
question that the changed ways of living here may materially affect the
further spread of the disease among the immigrants from Scandinavia.

But these few questionable points of criticism affect in no measure the
great value of the work. We can heartily commend it, not only as an
admirable text-book for teacher and student, but in its clear and com-
prehensive rules for diagnosis, its sound and independent doctrines in
pathology, and its minute and judicious directions for the treatment of
disease, as a most satisfactory and complete practical guide for the
physician. J. C. W.

Traitk de chirurgie de guerre. By E. Delorme, Medicin-Major de
Ire classe ; Professeur de clinique chirurgicale et de blessures de guerre au
Val de Grace. Tome Premier. Histoire de la chirurgie militaire

I KAVCAI8E, PLA8IE PAR ARMES A FEU DE8 PARTIES MOLLES. Al

figures dans le texte et une planche eu chromo-lithographie. Pp. viii. . 668.
Paris : Felix Alcan, 1888.

Treatise on the Surgery of War. By E. Delorme, Surgeon-Major of
the 1st class, etc. Volume I.

When the French army was beleaguered at Metz in 1553, the garri-
son, depressed by disease and injuries and hopeless of delivery,
almost on the point of surrendering, when Ambroise Pare' was conveyed
through the enemy's lines and brought into the city. The soldiers greeted
him with acclamation, crying, " We need have no fear of dying, now that
Pare is wit li us!" New spirit was infused into all hearts, and a stout
resistance to the enemy was maintained until the siege was raised. While
perhaps the personal influence of Pare has not attended all of his suc-
cessors, it is a noteworthy fact that from his day the French military

DILORMB, TREATISE ON SURGERY OF WAR.

surgeon has possessed great influence with his comrades and a high repu-
tation among his professional contemporaries. A work upon military
then, emanating from the school of Val de Grace, carries with
it much authority and is entitled to a most careful study.

Nut the least attractive feature of the work of Delorme is the extensive
review of French military surgery with which it is introduced. Occu-
pying a little more than half of the first volume, the space devoted to
the historical aspect of the subject is in marked contrast to that observed
in English and American works, and evinces a commendable and patriotic
scholarship. The sketches take the form of a series of brief biographies,
in connection with which the surgical work of the worthies treated of,
is presented. Although the series is arranged in chronological order, so
far as the lives of the subjects are concerned, the history of any particular

Erocedure can be obtained only by digging among the mass of disjointed
iographical sketches. It would seem that the history of the military
phase of the surgical art could have been better shown, had he arranged
his matter progressively, so as to show the growth of the various topics
involved.

A chapter of considerable length is devoted to the description of the
arms of modern warfare, including both cutting and piercing arms and
firearms. It is apparently intended to present an exhaustive discussion
of the subject, for the arms used by the principal powers are considered
in detail, giving the charge of powder, and the size, weight, and shape of
the projectile — the latter graphically. We have not the means at hand
for testing the correctness of his observations upon the arms of other coun-
tries ; but when he informs us that the United States Army is provided
with the "Remington-Springfield, calibre 58," the " Springfield-Reming-
ton, calibre 50," and the Berdan rifles, he is far from the truth. During
the War of the Rebellion, when an immense body of volunteer troops was
in the field, the arms were almost as various as the volunteer organiza-
tions which used them, and we believe that at one time pieces of calibre
50 and 58 were manufactured at the Springfield arsenal. But no such
varieties of ordnance as the first two named by Delorme were ever used
by our army, nor were any such ever manufactured. The Remington
rifle is used by certain militia organizations, but the only model used in
the United States service at the present time, and for a considerable
number of years past, is the Springfield breech loader, calibre 45, admit-
ting a cartridge containing seventy grains of powder, propelling a conical
projectile weighing five hundred grains with an initial velocity of thirteen
hundred feet.

The remainder of the volume is devoted to a consideration of wounds
involving the soft parts. Here M. Delorme falls into line with modern
surgery by prescribing antiseptic dressings for individual wounds, but it
is to be regretted that he has not seen fit to enter more at length into the
general consideration of the application of aseptic and antiseptic methods
in the treatment of wounds received in war. With all the machinery
of a well-equipped hospital, with ample skilled assistance, and with a
comparatively small number of cases, civil aseptic surgery has advanced
well on the road to perfection. But so much greater are the difficulties
with which the military surgeon has to contend, that the case is quite
different with the surgery of war. The problem of antiseptic dressings
amid the flying dust, the bewildering smoke, and the confusing roar of
the battlefield is s difficult one. But surely, starting from the founda-

58 REVIEWS.

tion laid by the civil surgeon, many advances in technique must have
been made. That the recent wars of the French, the campaigns in Tunis
and in Tonquin have not been entirely unproductive in this respect, is
very vaguely indicated however. German authors have been particu-
larly fruitful upon this subject, the recent work of Mosetig-Moorhof
being a case in point.

The importance of the first dressing cannot be too strongly emphasized
at any time, and its importance is all the greater in military surgery
where, because of the deluge of wounded, the first dressing must, in many
cases, be the only one for a considerable period. Accordingly the dress-
ings should be portable so that they can readily be carried by bearers
up to the line of battle itself, where the timely application of a suitable
dressing may prevent many a death. The apparatus of aseptic operative
work should also be reduced to a minimum in bulk and a maximum in
efficiency, for field hospitals and first dressing stations, in particular, are
subject to sudden removals. The technique of modern military surgery
then differs in essential details from that of civil life, and the absence of
a thorough discussion of these points in a work upon the surgery of war
is an inexcusable blemish.

His chapter on lesions of the bloodvessels opens with arteries, and
considers first contusions, proceeding then to penetrating wounds, illus-
trating, by drawings of his own specimens, a number of cases of lateral
and perforating wounds and complete sections. Here he introduces a
section on provisional hamostasis, showing the methods and localities for
the application of digital compression, with some remarks on prepared
and extemporized tourniquets. While noting the method of checking
hemorrhage in the leg or forearm by forced flexion of the knee or elbow,
he omits any reference to the method of obtaining this result by forcibly
Hexing a limb upon a hard, smooth surface, which is in most cases appli-
cable to wounds of the entire length of both extremities, and is an
exceedingly convenient temporary method of ha^mostasis.

In treating of wounds of the veins, he rejects the lateral ligature,
believing that, in view of the increased danger of recurrent hemorrhage,
total ligature is the preferable procedure. Neither does he refer to the
method of closing lateral incised wounds in large vessels by stitching the
lips of the wound together with fine aseptic sutures. On the whole,
however, his discussion of wounds of the vessels is excellent and reliable.

More than the usual amount of space is devoted to lesions of nerves,
the material for which is largely taken from the works of Mitchell,
Morehouse, and Keen, and other American sources. He, however, does
not speak of the distance sutures of his compatriot, M. Aflgaky, which
would seem to be particularly adapted to gunshot wounds, where the
continuity of a nerve is apt to be interrupted for some little distance.

Delorme is not an advocate of the primary antiseptic occlusion of
all gunshot wounds, holding that fragments 01 shell should always be
removed, and that gun or pistol shots should be extracted or left undis-
turbed, according to the tolerance of the parts and the form and condi-
tion of the missile. In this he takes a conservative position, rather in
opposition to the tendency of the day. Holding these views, it would
be expected that a complete study of the various bullet extractor* would
be presented, as is the case. He merely mentions, however, the electric
apparatus of Bell for locating a projectile, and entirely ignores the
valuable induction balance and telephonic probe of Gird ner.

CARTER, OPHTHALMIC SURGERY. 59

ndary complications of wounds of the soft parts, secondary hemor-
rhage, and the secondary complications of nerve wounds, together with
inflammatory troubles, tetanus and hospital gangrene are fully and ably
discussed. Injuries affecting the viscera, bones, joints, etc., are reserved
f>r tin- second volume, which will complete the work in 1889.

To an extent unusual in authors of his nationality, M. Delorme has
made use of the works of foreign writers, conspicuous among whom are
American surgeons. The labors of Otis and Huntington in the Surgical
Hi.-tory of the Rebellion have afforded him a treasure which he has used
freely. And while not complete as a guide to the actual practice of
militarv surgery, this work contains a mass of well-digested information
which will be of the greatest service to the student, and in reality marks
an advance in the study of the surgery of war. J. E. P.

Ophthalmic Surgery. By Robert Brudexell Carter, F.R.C.S., Oph-
thalmic Surgeon to St. George's Hospital, etc. ; and William Adams
Frost, F.R.C.S., Assistant Ophthalmic Surgeon to St. George's Hospital,
etc. Illustrated with a chromograph and ninety-one engravings. 12mo.
pp. 554. Philadelphia: Lea Brothers & Co., 1888.

The authors of this work come forward now, not as new candidates
for the attention of their professional brethren, but as those who, having
already well demonstrated their ability to discuss in a very clear and
agreeable manner the subjects here considered, will at once be accorded
attention to their new statement of matters both old and new.

In power to make the setting forth of their views entertaining, as well
as instructive, they are well matched ; and the piquant, forcible way in
which facts are presented serves to rouse fully the powers of apprehen-
sion in the reader, reducing to a minimum the effort of perusal, while
making the most vivid and lasting mental impression. As an instance
of the advantage this power gives an author, take this exposition by
r, of his objections to " the diathetic nicknaming " of iritis :

" There is one ground, however, on which I strongly object to this ticketing
of iritis with the names of various diseases ; namely, that the habit is likely
to mislead the inexperienced practitioner into an endeavor to treat the name
on the ticket, while the iritis may be neglected until it has done irreparable
harm. I do not know of any disease which prevents the occurrence of iritis,
and, hence, I do not know of any with which it may not sometimes be asso-
ciated. I have very little objection to its being described as ' syphilitic,'
because the description is in many cases accurate, and because it has no
tendency to interfere with, but rather to promote, the proper conduct of the
treatment ; but I do not know how to define the conditions under which the
epithet may be properly applied. . . . There are books from the perusal
of which one could rise with the belief that to distinguish between syphilitic
and non-syphilitic iritis would be a simple matter. A further examination
shows that the syphilitic iritis of one writer is the non syphilitic of another,
and that the symptoms which one regards as pathognomonic, are by another
regarded as unimportant. When we turn to other diatheses or constitutional
states, the confusion becomes worse confounded, and the practitioner, possibly
not thoroughly skilled in the management of eye-disease, but familiar with
rheumatism or with gout, is not to be overmuch blamed if he is led by the
'imposture and force of words' to attend to what he thinks he understands,

60 REVIEWS.

and to neglect that about which he feels less confident. I strongly hold,
therefore, that what I may call the diathetic nicknaming of iritis is to be
deprecated. It does but darken counsel, and puts empty phrases in the
place of knowledge. We do not understand a given case one whit better for
calling it ' rheumatic,' and the term tends to relegate to the second place, as a
mere accident of another affection, a malady in which all our skill will be
necessary if we are adequately to discharge our responsibilities to the patient."

Doubtless the main idea thus set forth could be stated much more
briefly, perhaps in one or two short sentences. But if these sentences
failed to arrest the attention of the reader and impress his memory, they
would be entirely worthless, and would constitute a statement infinitely
inferior to the one quoted.

If a concise rigid style has not been adopted, it may seem, on taking
up this manual, that the subject can scarcely be treated in a book of
its size without some serious omissions. But a careful search shows that
none have been made. The authors have avoided extended quotations,
either from their own earlier writings, or those of others ; and a quota-
tion is very apt to be, to some extent, a repetition, and to require a
certain amount of introduction, and so becomes a great consumer of
space. Nor has the work been expanded with " copious references,"
illustrating the breadth of the authors' reading, or with numerous cases
mainly suggestive of their great experience. And the condensing of the
work to the size of a " clinical manual " has been largely due to the use
of thin paper, of which comparatively little is wasted in margins ; the
book probably representing as much " copy " as the treatise of Juler,
which occupies double the space on the book-shelf.

In his earlier writings, Mr. Carter has laid considerable emphasis upon
certain observations that seem to leave it very much in douDt whether
the disorder of vision commonly ascribed to the excessive consumption
of tobacco was really connected with the use of that narcotic. Remem-
bering this, it is of interest to note that he now says :

" The cases of tobacco amblyopia which I have recognized, and in which
the diagnosis has been confirmed by restoration of sight when the tobacco
was abandoned, have been attended by some pallor of the optic nerves, with
no effusion or blurring of their outlines, and by perfect knee-jerks. By the
last-named symptom the cases have been discriminated from early stages of
locomotor ataxy, to which, as far as the state of the optic nerves ami vision
were concerned, they bore a great resemblance. My colleague, Mr. Frost,
who has seen a large amount of tobacco amblyopia among out-patients, is
of opinion that in the earlier stages the disk margins are a little hazy, and
that this condition is succeeded by pallor of the outer half of the nerve."

Though no allusion is made to his former argument, throughout his
account of the affection, as in the above extract, the views expreaveel
are entirely in accord with those most generally held by ophthalmic
surgeons at the present day.

As a substitute for enucleation, evisceration or exenteration, ami the
Mules' operation," a great improvement on it, as far as the cosmetic
effect is concerned," are mentioned favorably by both authors; and Mr.
Frost very frankly states the objection to complete enucleation and the
insertion of a glass sphere in the capsule of Tenon, the substitute tor the
Mules' operation proposed by himself. But the credit for the first pro*
■ ration is here, as by other European writers, given to
Alfred (iriife. Now, although Griife proposed it at the Congress of

CARTER, OPHTHALMIC SURGERY. 61

German Naturalists ami Physicians, in September, 1884, probably
without knowing that it had previously been proposed and resorted to,
the tact is that it had been proposed, and a case in which it was per-
formed reported in the Trxmmuhotu of the American Ophthabnological
ly for 1878, by Dr. EL W. Williams, of Boston. It is true that
Williams had intended to do merely an abscission, and removed the
whole contents of the sclera only because he found an ossified choroid,
and had promised the patient that he would not enucleate. But, having
thus been led to perform the operation, he proposed it as a common
substitute for enucleation, and gave a very good account of its special
advantages and disadvantages.

In general, the authors seem quite familiar with American work on
ophthalmology, though they credit Dr. Prince, of Illinois, with his
tendon advancement operation, to Philadelphia; and describe and figure
as "the Loring-Noyes ophthalmoscope" an instrument that smacks
strongly of John Bull, and which, with its three mirrors and its handle
" of sufficient size and weight to be firmly grasped, and to balance the
other parts of the instrument," would constitute no mean weapon in
haml-to-hand combat.

The work throughout is marked by its practical character and good
common sense, which makes a lapse like the following all the more
striking :

"A9 in the camera, the image formed upon the retina is inverted, and the
means by which this inverted image is made to convey a correct impression
to the sensorium has been a subject of much dispute among philosophers.
The most probable explanation is based upon the positions of the retinal
bacilli, which are radial to the centre of the eyeball; so that a bacillus in
the upper part of the retina, which receives the image of the lower part of an
object of vision, may be said to be looking down toward it, and hence to pro-
ject it into its right position. The same principle would apply, of course, to
all other parts of the retinal surface."

That this question of the erect perception of objects by the aid of an
inverted retinal image has puzzled every dabbler in optics and raw
student of ophthalmology, cannot be denied ; and it has even revealed
a lamentable mental haze where we would not otherwise have expected
it (see the first number of this journal, November, 1827, p. 163). But
Kepler, when he first set forth the facts regarding the retinal image,
nearly three hundred years ago, fully explained the matter ; and those
who would like a particularly full presentation of that explanation,
which has never been intelligently questioned, should consult Porterfield
on the Eye, published in 1759. The fact is that we are net in any way
directly conscious of the existence of a retinal image, much less are we
conscious of the relative positions of its various parts. Each separate
ray of light makes its impression on one particular part of the retina,
giving rise to an impulse which travels by a particular nerve path to
influence a particular group of brain cells. By experience, and by
experience alone, we learn to associate the stimulation of this par-
ticular portion of the sensorium with a certain direction of the object
whence the light comes, and so learn to judge of the relative positions
of objects. Because light falling in a certain direction always influ-
ences the same group of retinal cones, nerve-fibres, and central ganglion-
cells, we are able to judge relative positions correctly. But the actual
or relative position of the cone influenced has no more to do with that

vol. 96, HO. L— OUT, 1888. 5

62 REVIEWS.

judgment than has the position of the nerve-fibre or ganglion-cell
involved in the process. Will not the "philosophers" stop the " dis-
pute" over the inverted retinal image and the correct projection of
objects, and explain why parallel lines appear parallel lines, although
the optic nerve fibres are inextricably tangled ? Or why a plane seems
a plane, although the perceptive cerebral cells are grouped in some
totally different geometrical relation ?

Such an attempt might at least reveal the folly of confusing the ob-
jective and subjective phenomena of any given act ; and so finally termi-
nate the dispute in question. E. J.

The Surgical Diseases of the Genito-urinary Organs, including
Syphilis. By E. L. Keyes, A.M., M.D., Professor of Genito-urinary
Surgery, Syphilology, and Dermatology in Bellevue Hospital Medical
College ; Surgeon to the Charity, the Bellevue, and the Skin and Cancer
Hospitals; Consulting Surgeon to the Bureau of Out-door Relief, Bellevue
Hospital; Surgeon to St. Elizabeth Hospital, etc. 8vo. pp. xv. 704. New-
York : D. Appleton & Co., 1888.

This handsome volume is not merely a new edition of the well-known
work of Van Buren and Keyes, but a complete revision of that text-
book. The original plan of the older work has been retained, and its
scope remains the same; but it has been entirely recast, and in a large
measure rewritten.

This course has been made necessary by the vast progress which has
marked the history of surgery during the last ten years, especially in the
field of therapeutics and operative procedures. To bring the book up
abreast of the times upon the new device of litholapaxy, suprapubic
cystotomy, the modern surgery of the kidney, the treatment now followed
in diseases of the tunica vaginalis, and the many minor changes which
find expression in the use of new agents, Dr. Keyes was compelled to omit
many things, to add considerable new matter, and largely to modify much
of the remainder. Some chapters are entirely new, and in order to make
room for desired additions all the cases have been dropped.

Of course, such radical changes interrupt the historical sequence of
the volume, and detract somewhat from the vividness of the picture
belonging to the narrative. But such considerations belong to literatim-
and must be disregarded in practical scientific works, and although Dr.
Van Buren's part in the volume has been almost altogether eliminated.
the result is eminently satisfactory from a surgical standpoint. As it
now stands, it is a treatise which may safely be consulted and which fairly
and freely speaks of the most modern methods. Dr. Keyes is enthusi-
astic in his commendations of litholapaxy, and cordially endorses the
high operation for stone, while he decides that the time-honored and
brilliant nut hods of reaching the bladder through the perineum an- only
applicable in the cases of male children with stones of moderate size.

Dr. Keyes says the book "is an honest exhibit of my views upon all
the subjects considered," and as his experience has been large, and his
skill and prudence are undisputed, we have no hesitation in saying there
is no one in this country whose judgment is more worthy of eonlidenee.
or whose directions may be more Barely followed. S. A.

JACOBI, INTESTINAL DISEASES OF CHILDHOOD. 63

Tin Im imixal Diseases ok Infancy and Childhood. By A. Jacobi,
M.D., President of the New York Academy of Medicine, etc. Pp. 301.
Detroit : George S. Davis, 1887.

A book seasonable, piquant, and useful ; answering the need of the
mental organism for alterative and acid food after a winter of heavy diet.

To the author's mind " Infant hygiene and the hygiene of the digestive
organs in infants appear to be nearly identical ;" and the best hygiene is
to be secured by feeding with mother's milk. This failing, patent foods
are rejected, and average cow's milk, boiled, and oatmeal- and barley-
water, with animal broths, white of egg and alcoholics are relied upon.
Irrigation of the intestines is highly valued, and the intestinal antiseptics
recently approved are described and generally commended.

It is interesting to notice that in his large experience Jacobi has lanced
the gums but twice in five years. With many Continental writers, he
believes disorders caused by dentition largely errors in diagnosis. His
treatment of intestinal parasites is based on fundamental principles of
■logy — make the environment disagreeable to the worm and he will
■uate — and the various intestinal disorders of the child receive a like
trenchant and effective treatment.

Beginning the book is an epitome, by subjects, of the feeding to be
employed with the healthy child, which is most convenient for reference.
The book is written in paragraphs of varying length ; and is admirably
adapted for a hand-book.

Knowledge is rarely made so appetizing, so clear, and so useful as in
this volume. E. P. D.

Hydrophobia. An Account of M. Pasteur's System. Containing a
Translation of all his Communications on the Subject, the Tech-
nique of his Method, and the latest Statistical Results. By
Bernard Suzor, M.B., CM. Edin., and M.D. Paris. With seven illus-
trations. 12mo. pp. 231. London : Chatto & Windus, 1887.

The author of this little work was commissioned by the government of
Mauritius to study Pasteur's system of anti-rabic inoculation, in Paris.
Its scope is indicated by the sub-title, and it is evidently written for a
popular, or at least non-medical circle of readers. The choice of title is
rather unfortunate. We think it much better to substitute " rabies," as
less misleading than hydrophobia and more in consonance with the usage
in other languages.

The book is divided into three chapters, of which the first is intended
to give a "short description of hydrophobia from the earliest times down
to the end of 1880." It is taken up almost exclusively by a fairly accu-
rate description of the symptoms and post-mortem appearances of rabies
in dogs and man. We cannot pass without condemning the rule quoted
from Bouley (p. 17), that immediate destruction of all animals suspected
of having been bitten by a rabid animal is to be preferred to keeping
the same under observation. Dogs killed under such circumstances are
always classed as rabid and their victims doomed to certain death,
whereas time, and, if possible, control inoculations, would show a
favorable termination in many cases.

64 REVIEWS.

Chapter II., which forms more than half the book, will probably be
skipped by most readers. Although tiresome in parts it should be read,
for there are many passages in it that throw a great deal of light on
Pasteur and his methods in general, and of the anti-rabic inoculations
as now practised. The chapter, however, is not entirely candid, proba-
bly owing to the necessary brevity. Thus we read in several places of
the nineteen Russians from Smolensk, and the sixteen who returned
cured. It was our impression that the deaths of the "survivors" were
chronicled with painful frequency from time to time after their return,
and it was only then we learned that wolf bites are so much more
dangerous than those of other rabid animals.

Chapter III. is the most entertaining in the book. It gives a vivid
and accurate description of the inoculations as practised by Pasteur
and his disciples, and of the scenes daily witnessed in the laboratories in
the Rue Vauquelin and Rue d'Ulm. The author's enthusiasm, how-
ever, leads him to conclusions that are rather too sweeping. The thanks
of the scientific world are due to Pasteur for the completeness witli which
he has investigated canine rabies. That this necessitates the erection of
" Institutes " in all countries where rabid dogs occur by no means follows.
Wolves, jackals, and other French and Russian terrors do not exist for
us, and with the example of Germany before us, where well carried-out
dog laws have practically annihilated rabies, we should consider the
erection of such an Institute as a step in the wrong direction and a
reproach to our common sense and our civilization.

With the limitations we have suggested, Dr. Suzor's book may be
recommended to all who wish to obtain an idea of Pasteur's " system."
The mistakes in diction and proof-reading are few, and the mechanical
part well executed. The " seven illustrations " strengthen the idea that
the work is intended for popular circulation. G. D.

A Movable Atlas, showing the Progress of Gestation, by Mi
of Superposed Colored Plates. By Professor Witkowski, M.D.,
Member of the Paris Faculty of Medicine. Text translated by R. Mii.ni:
Murray, M.D., M.B., F.R.C.P.E., Lecturer on Midwifery and the Diseases
of Women in the Edinburgh School of Medicine. London: Ballirre,
Tindall & Cox, 1888.

As the name implies, the atlas contains a female figure whose organs
are colored to represent nature, and from which successive layers may
be removed, showing the tissues of the abdomen in their anatomical
relations at various periods of pregnancy.

Accompanying the atlas is the text, in pamphlet form, written by
Professor Pajot. It is a fair exposition of the views of French obstetri-
cians, in concise form, adapted to British readers by the translator. The
French beliefs regarding the treatment of contracted pelves and the use
of the forceps are given, and many of the most valuable points in prac-
tical obstetrics have been added by the translator. Atlas and text
furnish, in a convenient shape, information which is in the possession of
the profession in other forms, and by those to whom diagrams are of
benefit, will be found of interest.

PROGRESS

MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

ROBERTS BARTHOLOW, M.D., LL.D.,

PROFESSOR Or MATERIA MEDICA, GENERAL THERAPEUTICS, AND HTOIENC IN
THE JEFTER80N MEDICAL COLLEGE Or PHILADELPHIA.

The Relation of the Atomic Weight of the Elements to their
Biological Action.

Dr. Blake, of San Francisco, has distinguished himself by his investiga-
tion of this abstruse subject, in which, indeed, he is a pioneer, and fairly
divides the honor of priority with Prof. Crum-Brown, of Edinburgh. In
this paper, to which we call the attention of our readers (Archives de Physiol-
ogic Normcde ct Pathologiques, May 15, 1888), he states anew the results of his
investigations. He had already demonstrated the important relation of iso-
morphism and the atomic weight to the action of the metals. By the last
investigation he has shown that the biological action of the monatomic ele-
ments is exerted principally upon the pulmonary artery; of the biatomic
elements upon the centre for vomiting and the cardiac and voluntary mus-
cles ; the triatomic upon the respiratory centre, the vasomotor, inhibitory,
the cardiac ganglia, and the pulmonary artery ; the tetratomic, upon the
nerve centres, of the brain and cord, and on the cardiac and pulmonary
ganglia.

Although these studies may have but little practical utility at present, they
must ultimately serve an important purpose.

Action of Spirituous Drinks on the Liver.

Dr. Zenox Pupier publishes {Archives de Physiologie, May 15, 1888) an
elaborate paper on the effects of various forms of alcoholic drinks on the
structure of the liver. This careful physiological research confirms previous
observations on the action of alcohol. Dr. Pupier finds that the prolonged
use of alcoholic drinks — absinthe, red wine, white wine, alcohol — produces
well-defined effects.

Separating the water of the tissue, it causes a desiccation that includes
structural changes.

66 PROGRESS OF MEDICAL SCIENCE.

Nutrition is retarded and fatty deposits occur, corresponding, for example,
to the steatosis of atheroma. At a more advanced stage, it disintegrates the
membrane, reducing it to the fibrillary state, promotes the deposition of lime-
forming cretaceous masses, and advances to the stage of sclerosis.

There are peculiarities in the character of the pathological changes belong-
ing to each form of alcoholic fluid. Absinthe alcoholic drinks cause changes
typically cirrhotic. With white wine the cellular degradation is especially
pronounced.

Oleander [Nerium OleanderJ.

Dr. Poulaux (Bull. Gen. de Therap., May 15, 1888) has recently made an
elaborate investigation, physiological and clinical, of oleander. This plant
has long been known, and many cases of poisoning have been reported. It
was first administered internally in 1818, and the last research into its physio-
logical properties, except this one of our author, was made by Prof. Schinie-
deberg (Archiv der Path, experiment., etc , vol. xvi.).

Oleander is a member of the family Apocynaceoz, an evergreen, and grows
most luxuriantly near the water. Climate exercises an important influence
over its several constituents. The bark contains a greater proportion of its
active principles than any other part of the plant.

According to Schmiedeberg, oleander contains an alkaloid, which he has
named neriine, and which has properties like those of digitaline; oleandrinr,
which corresponds to digitate, and a glucoside, nerianitin, which acts in a
manner similar to digitaline. The reader not familiar with Schmiedeberg's
analysis of digitalis, needs to be told that he has assigned the names above
given to the products of his analysis of commercial digitaline.

Meco-narceine.

M. Laborde, well known for his investigations into the physiological
actions of remedies, has recently reported on the actions and uses of a new
form of an old remedy (Revue de Therapeutique, May 15, 1888). He entitles
the new remedy Meco-narceine. Discovered by Pelletier, narceine was studied
by Bernard, who ascertained that it has hypnotic properties and is not poi-
sonous. The difficulty in obtaining it in a pure form, and its exceeding in-
solubility, discouraged its use.

Laborde finds that this substance, designated by him Mrco-narceinc, is the
alkaloid narceine, to which some other unknown alkaloid adheres, and thai
the combination can be utilized as a remedy. He has ascertained that it
possesses hypnotic properties, and moderate! the activity of the respiratory
and cardiac excito-motor or reflex functions.

Be lias employed Meco-narceine in pill form, and in a mixture with syrup,
In the dose of one-twelfth to one-sixth of a grain. The sleep produced by it
ia tranquil and is not followed by unpleasant after-effects.

He has prescribed it successfully in cases of wakefulneas due to nervous-
ness, or occurring as an inci. hut to chronic diseases, and in bronchial affec-
tions to relieve ooagh, and to diminish the expectoration. It has proved
useful, also, as a remedy for recent neuralgia.

THERAPEUTICS. 67

SULPHONAL.

The new hypnotic has been the subject of much study and experiment. In
the Berliner klin. Wochen., Nos. 16 and 17, 1888, there are papers by Prof.
K \tn and Dr. G. Rabbas — the former a physiological, and the latter a clinical
papi r.

finds that it does not materially affect the frequency of the pulse and
respiration ; only by large doses is the blood pressure lowered to any extent.
The sleep caused by it is like the natural state, and when normal sleep occurs,
it is greatly prolonged.

finds himself in a position to recommend sulphonal as a hypnotic of a
reliable character, although not to be considered phenomenal. Its special use
is as a means of promoting sleep at its regular and accustomed periods. The
duration of the hypnotic effect ranges between one-half to two hours, from
small doses, to five to eight hours, from the maximum. The patient emerges
from the hypnotism, free from the usual unpleasant effects which follow other
agents of the kind.

Rabbas reports the experience of the Marburg clinic. He says that as a
hypnotic sulphonal is superior to amylene and paraldehyde. As compared
with chloral, its action is not so profound, but the duration of the effect is
longer.

Sulphonal is not difficult to administer: its taste is not disagreeable, and it
can be given in the form of powder, or in simple solution. The dose ranges
from 15 grains to 3>j-

Treatment of Venereal Diseases.

The abortive method of Mr. Hutchinson, to which we called attention in
our last issue, has provoked considerable discussion. We submit to our
readers some of the more important practical observations which have ap-
peared recently. As representative of a French school of syphilographers,
we give below an abstract of M. Ch. Mauriac's conclusions {Revue de Thera-
peutique, May 15, 1888) in a paper treating of gonorrhoea.

The abortive treatment of gonorrhoea is possible only in a case that has
been in existence but a few hours, and such attempts during the acute period
are not only useless but dangerous. He holds, also, that the microbe theory
as a basis for treatment is illusory. An antiphlogistic method, up to the dis-
appearance of the acute symptoms, is necessary. The " repressive treatment,"
of copaiba and cubeb internally, and sulphate of zinc by injection, is the
most effective ; this to be undertaken only after the complete subsidence of
the acute stage.

If French therapeutics continues according to the old traditions, as M.
Mauriac's paper indicates, it is only another proof of the decadence of their
great school.

English opinion of the conservative kind is represented in the paper of Mr.
F. W. Lowndes, which has just appeared in The Lancet of May 26, 1888. He
treats of all the forms of venereal diseases, and his opinions are based on exten-
sive observations, during thirty years. It would seem that the old traditions
still rule in England also, for Mr. Lowndes says : " I have found that this treat-
ment (antiphlogistic, followed by the repressive) holds its own up to the present

68 PROGRESS OF MEDICAL SCIENCE.

day." This ancient method consists of "an antacid mixture," containing
liquor potassae, tincture of hyoscyamus and nitrous ether, followed by copaiba
paste, which includes cubeb, hyoscyamus, and camphor. For injections he
adheres to zinc chloride — one grain to four ounces — and adds a very little
tincture of iodine.

As to the treatment of syphilis, Mr. Lowndes is an advocate of the mer-
curial. Hydrargyrum cum creta for internal use ; mercurial inunction and
mercurial vapor bath, to procure systemic action, and locally "black wash"
which "still holds its own," mercurial ointment, and iodoform — the un-
pleasant odor of which he overcomes by adding a few grains of ground coffee.
He finds inunction the most effective treatment and next in value to the vapor
baths.

He has nothing to say of the hypodermatic method, nor does he allude to
microbes, and the necessity of germicides.

For application to mucous patches and ulcers of the mouth, he finds noth-
ing better than chlorate of potash, and a mixture of iodoform and starch in
equal parts, blown on with an insufflator.

For the tertiary, to which he restricts it, Mr. Lowndes uses the iodide of
potassium. The addition of acetate of potassium — fifteen grains to each dose
— he finds permits the iodide to be used with much less irritation. The alter-
nate— week by week — use of iodide of iron is very effectual for the relief of
tertiary when there is much depression of the vital forces.

Antipyrin in Whooping-cough.

Dr. Dubousquet-Labordiere finds that antipyrin is an efficient remedy
for whooping-cough {Revue Gen. de Therapeutique, May 15, 1888). He con-
cludes a clinical paper on this topic with the following :

1. Children take antipyrin without difficulty, and they easily bear its
effects, as a rule.

2. The spasmodic condition is rapidly calmed, and in a few days the dis-
ease declines.

3. Its action is so prompt and so free from accidents, that it becomes a
valuable remedy for a malady which may be very prolonged in duration, and
have many complications.

Antipyrin versus Analgesine.

At a recent session of the French Academy {Revue de Therap., May 15,
1888), M. BOURGOUIN proposed substituting the word analgesine for anti-
pyrin, on the ground that the latter is not a succedaneum for quinine, and is
a pain reliever. Dujardin-Beaumetz opposed the suggestion on the ground
that, the name antipyrin having come into universal use, to change to anal-
gesine would cause confusion.

Salicylate of Soda in Albuminuria.

Jaccoud (Revue de Thkrapeutique, May 15, 1888) advises caution in the use
of salicylate of sodium in cases of albuminuria. He finds that five grammes
(eighty grains) in twenty-four hours suffice in cases of acute rheumatism.

MEDICINE. 69

When albuminuria appears, he stops the administration of the remedy ; and
also in fevers, should albuminuria occur, the salicylate is discontinued, and,
in place of it, he gives the bromhydrate of quinine.

For Nasal Catarrh.

R. — Chloral, hydrat gr. x.

Acid, boric 5U-

Glycerini,

Aquae laur. ceras aa 3j.

Aqua? . syj — M.

Sig. — Apply locally.

'• Magic Cream" (Lowndes).

R. — Hydrarg. ammoniat 1 part.

Zinci oxidi 3 parts.

Must be thoroughly incorporated in powder, sufficient glycerine and lard
then added to make a stiff cream. For application to venereal ulcers.

The same can be extemporaneously prepared by mixing one part of the
ammoniated mercury ointment with three parts of zinc ointment, and a little
glycerine added.

Menthol Plaster.

Lead plaster 75 parts.

Yellow wax 10 parts.

Resin 5 parts.

Melt the resin, and thoroughly incorporate with it — Menthol, 10 parts.

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLER, M.D., F.R.C.P. Lond.,

professor or clinical medicine in the university or pennsylvania.
Assisted bt

J. P. Crozer Griffith, M.D., Walter Mendelsox, M.D.,

ASSISTANT PHYSICIAN TO THE HOSPITAL OP THE PHYSICIAN TO THE ROOSEVELT HOSPITAL, OCT-

CNIVERSITT OP PENNSYLVANIA. DOOB DEPARTMENT, NEW TORE.

Typhoid Fever a Children*.

In a clinical lecture on this subject, Forchheimer (Jfe** Orleans Med. and
Surg. Journal, April, 1888) emphasizes the fact that the disease in children
almost always begins suddenly. The child will be playing about in the
morning, languid in the evening, and quite ill by the next day. Insomnia is
frequent at night, often alternating with drowsiness during the day. Iliac ten-

70 PROGRESS OF MEDICAL SCIENCE.

dernes9 will be elicited on deep pressure. Epistaxis occurred in only five per
cent, of seventy cases which he has recently treated, though in some epidemics
it is frequent. Sneezing is sometimes seen, contrary to Liebermeister's dogma.
The tongue is as in adults. Bronchial catarrh and cough are nearly always
present. Constipation is much more common than diarrhoea, which, how-
ever, usually occurs some time during the disease. Enlargement of the spleen
has not the same importance as in adults, and, though generally present, may
be wanting. Vomiting is very common, especially at the inception. The
lesions of the bowel are much less severe than in adults, and only one of the
seventy cases had hemorrhage, and none perforation. The greatest character-
istic is the profound impression on the nervous system, which often persists
to some extent for years. The pulse does not rise in proportion to the tem-
perature ; the heart not being severely affected. Complications are not fre-
quent, the commonest being aphasia, of which we have no explanation. A
sequela not occurring in adults is tuberculosis of the intestines, lungs, or
meninges. The prognosis is very favorable, as up to the age of twelve years
the mortality is hardly over five per cent. For treatment he uses the abor-
tive method with calomel, antipyrin to lessen pain and for its antiseptic
effect, absolutely liquid diet, the use of a day and a night bed, the lukewarm
bath, whiskey, often dilute nitro-muriatic acid.

The Duration of the Incubation of Measles.

Lee (Medical Press and Circular, 1888, xcvi. 430) reports several cases of
rubeola which are interesting, since in most of them the duration of incuba-
tion could be accurately fixed. In 2 of them there was an interval of four-
teen days from the day of exposure, in 1 seventeen days, in 1 eighteen days,
and in 1 thirteen days.

Diphtheritic Inflammation of the Throat in Scarlet Fever.

Jackson (Boston Med. and Surg. Journ., 1888, cxviii. 421) reports his ex-
perience with fifty cases of scarlet fever, which is of interest as concerns the
real nature of the diphtheritic inflammation of the throat ; Eichhorst regarding
it as possibly true diphtheria, while Flint, Henoch, and Striimpell consider it
anatomically identical, but etiologically distinct. The chief arguments used
against it being diphtheria are (1) invasion of the larynx is rare; (2) paral-
ysis seldom follows; (3) it is not so fatal as true diphtheria. The author's
cases refute these claims, since one patient, and possibly two, died from in-
vasion of the larynx ; two died of paralysis of the heart after convalescence
was well established; and the mortality was large — i. e., four out of the eight
who suffered from the inflammation of the throat.

Hysterical Fever.

Under this title Bressler (Med. Record, 1888, 33, 466) calls attention to
an affection which is not, he says, described by authors generally, but of
which he has seen a number of cases; namely, an elevation of temperature
lasting from a few hours to several weeks, sometimes with intermissions, oc-
curring in neurotic individuals, and associated with symptoms of a hysterical

MEDICIXK. 71

character. We know nothing as to its anatomical changes; these being prob-
ably the same as those which operate in hysteria, plus an influence acting on
the thermic centre. The disease usually begins with chilliness, anorexia,
constipation, coated tongue, headache, elevated temperature, etc. The mind is
unusually bright, the special senses are acute, there is no delirium, no matter
how severe the attack may be, the appetite is often perverted, the patient is
irritable, and noises are often annoying and increase the fever. One of the
most important symptoms is the vomiting which often persistently follows the
introduction of anything into the oral cavity, and the patient will sometimes
go days without tasting food through fear of this. The abdomen is extremely
sensitive to pressure, but, unlike peritonitis, the pain is fluctuating and there
is no tympanites, while the one is further distinguished from the other by the
constant and characteristic ovarian tenderness, the variability of temperature,
etc. The pulse is usually increased in frequency. Neuralgia of the bowels,
insomnia, and hysterical asthma are seen exceptionally. The temperature is
peculiar, generally attaining a high degree early in the disease, and continuing
thus, or being subject to all sorts of sudden variations. Very little wasting of
the body takes place. The treatment is the same as for hysteria, with the
addition of some febrifuge ; antifebrin being the most satisfactory. The patient
must also be made to take food ; and symptoms treated on general principles
as they arise.

CONTRIBUTION TO THE PATHOLOGY AND THERAPY OF LEUKEMIA.

In an elaborate article on this subject, in the Zeitschriftfiir kimische Med-
icin, 1888, xiv. 80-147, Sticker reports, in fullest detail, a fatal case which
had been under observation eight months, and on whom numerous scientific
studies were made ; and then discusses some of the symptoms of the disease.
W« may note that as regards the blood the case teaches that the increase or
decrease in the number of the white blood-cells keeps pace with changes in
the symptoms, except the constant growth of the spleen ; or rather precedes
them somewhat. This case further shows the greatest number of white blood-
cells yet reported ; equalling at one time 3,743,000, or a proportion of 1 : 0.5.
The smallest number of red blood-cells in leukaemia is reported in a patient of
Sorensen and Quincke, and equalled 500,000 in the cubic millimetre. The
case of Sticker also confirms the statement that the number of the white
blood-cells increases, as that of the red diminishes; and disputes the oft-
repeated claim that there exists a diminution in the volume of the blood.
There is rather a hydraemic plethora. The frequency of the pulse and of the
respiration appeared to be nearly independent of the general condition of the
patient. Toward the last there existed an abundant bronchial catarrh, which
was found to consist almost entirely of the " eosinophilous" cells; while, at
the same time, the number of white blood-cells was found to have diminished
decidedly, and it is almost certain that they were eliminated by the bronchial
tubes. Priapism was present, as in many cases, but had certainly nothing to
do with the genital function. There was found no fatty degeneration of the
organs, in contradistinction to anaemia ; confirming Cohnheim's statement.
The retinal changes, which were extensive, are detailed at length. Late in
the affection there was disease of the labyrinth of the ear.

The author made an elaborate investigation into the metabolism in his

72 PROGRESS OF MEDICAL SCIENCE.

case, as shown by the analysis of the urine, and found that during the whole
eight months it was abnormally great, and increased with the growing
cachexia. Urea and uric acid were always in excess. The increasing number
of the white blood-cells certainly has an important relation to the increased
elimination of nitrogen. It is very probable that the degeneration of the liver
present produced a diminution of the formation of urea, and an increase of
that of uric acid; but it is certain that it was not able to paralyze the agents
which would cause an augmentation of the first, and a lessening of the
second. The enlargement of the spleen hid nothing to do with the increased
excretion of uric acid.

As concerns the therapy, the author believes that the very marked im-
provement, which was seen for a time, was undoubtedly due to inhalations
of oxygen ; a case having been also reported by Kirnberger where recovery
followed this treatment. This may be by supplying oxygen to white blood-
corpuscles, which otherwise consume all they have before the tissues can profit
by it; it having been proved that the leucaemic organism has a diminished
oxidizing power. The r6lc of arsenic in the therapeutics of leucaemia is not
yet positively determined, and needs further study. Quebracho was of great
benefit in this case in relieving the severe dyspnoea ; and has been also
recommended by Fleischer and Penzoldt.

A Study of Arterial Tension in Neurasthenia.

Webber {Boston Med. and Surg. Journal, 1888, cxviii. 441) has been
making a series of studies with the sphygmograph on the condition of the
bloodvessels in neurasthenia, and details a number of cases with sphygmo-
graphic tracings.

He concludes that neurasthenic patients may be divided into several
classes : First, those in whom the vascular tension is nearly or quite normal.
These patients are only temporarily run down, and soon recover. Second,
those who, at first, show a decided loss of vascular tone, but who regain a
normal tension after a course of treatment. These patients usually recover
after a longer or shorter time. Third, those whose vascular tone is very
much below normal, and whose tension sometimes apparently increases, and
then again loses ground. These cases do not improve much, and whatever
is gained is of doubtful permanency, owing to a lack of vascular stability.
In a few cases the early tracings showed a nearly normal condition of the
bloodvessels, but later ones were less favorable ; there being always some
cause to which the change could be ascribed. Some of the worst cases exhib-
ited a great variation of tension within a few minutes. The author concludes,
further, that the sphygmograph is an aid in determining the amount of ex-
haustion ; and by comparing tracings indicates the progress toward recovery.
A fictitious gain may be distinguished from a real one, since none is genuine
unless the tension of the arteries is permanently restored. Tracings should
be taken once in two or three weeks.

Some Clinical Features of the Uric Acid Headachi:.

Haio, in St. Bartholomew's Hospital Reports, vol. xxiii. p. 201, defines this
as a headache recurring at intervals of three days to a week, or from that to

MEDICINE. 73

one or several months, throughout a large number of years in the life of an in-
dividual. It lasts from twelve to twenty-four hours and then goes completely
away until the end of the interval. The attacks are rendered less frequent and
leas severe by a diet poor in nitrogen. There is often a family history of head-
ache, or gout, or both. The author has frequently found this headache asso-
ciated with a large excretion of uric acid, and has noted that the administra-
tion of an acid will stop the excessive excretion of uric acid and remove the
headache in one to one and a half hours. He reports several cases in full,
together with a tabular arrangement of the principal features of interest.
The headache is probably caused by the action of some poison in the blood
acid) on a nervous (vaso-motor) system especially sensitive in some
parts of the cranial circulation. Strychnine is sometimes very useful in this
headache on account of its tonic action on the vaso-motor centre. Symp-
toms of gastro-intestinal derangement are notable by their absence. The
tongue is clean, the bowels regular, food is well taken, the pulse is slow, and
the temperature normal. This is in marked contrast to the frontal headache,
furred tongue, fever, rapid pulse, and disgust of food, of real gastro-intestinal
derangement. The sulpho-cyanide is usually in excess in these headaches
occurring in gouty or rheumatic families, as Fenwick has remarked. The
author then lays stress upon the alliance between these headaches and epi-
lepsy, as illustrated by one of his cases, in which the two affections appeared
to improve together under a proper diet.

The Mortality of Epilepsy.

Doubting the truth of the general opinion that epileptics rarely die of epi-
lep-y. Worcester (Med. Record, 1888, 33, 467) undertook some statistical
investigations regarding it. For this purpose he examined the records of the
Michigan Asylum for the Insane, for the last twenty-eight years, as well as
those of fifty-five other asylums, fifteen of which give statistics for their entire
periods of operation. The results show that from twenty per cent, to thirty
per cent, of the epileptic inmates die of epilepsy, the rate being often much
nearer the latter figure. This is a much larger number than the total death-
rates of the individual asylums ; and shows, further, that not only is epilepsy
a very fatal disease, but that many more epileptics die from it than from all
other causes put together.

As to whether conclusions thus drawn are applicable to patients outside of
asylums, the author admits that the inmates of such institutions are probably
cases of more than average severity, but claims also that they are more favor-
ably situated as regards treatment and security against accidents ; and he
believes that the figures represent fairly the facts for cases of considerable
severity.

Notes on Pneumonia.

Wagner discussed some interesting points concerning pneumonia, in the
Deutsche* Arehiv fiir ktinische Medicin, B. xlii. H. 5, 1888.

I. Relapsing pneumonia. The difficulties connected with this subject are
to determine : first, whether a relapsing pneumonia was really a true croupous
affection ; and second, on and after what day a relapse may take place.

74 PROGRESS OF MEDICAL SCIENCE.

The author's opinion is, that a relapse has occurred when a new infiltra-
tion of the old or of other lobes appears, with all the general and local
symptoms of the disease, at least three days up to several weeks after the
lungs in croupous pneumonia had become entirely normal, the fever had dis-
appeared, and the patient had been completely convalescent. Relapsing
pneumonia, the pneumania a rechute of the'French, is certainly of very rare
occurrence. It develops, according to See, on the fifteenth or sixteenth day
of the disease, and has all the symptoms of the initial attack, but lasts only
two or three, or sometimes five or six days ; being thus of an abortive type,
like the relapse in typhoid. In about 1100 cases of pneumonia during the
last ten years, Wagner has seen only three doubtless instances of it, and
several doubtful ones. He also saw one case fifteen years ago, which he
reports with the others. Certain conditions may be confounded with the
relapsing pneumonia ; among these are the pneumonia with pseudo-crises, in
which the fall of temperature does not last more than a day. So, also, some
cases of wandering pneumonia, and many instances of secondary broncho-
pneumonia, which often recur repeatedly within a short time without any
known cause.

II. The cause of contagious pneumonia. Three years ago, the author reported
a series of cases of pneumonia of a typhoid type, occurring in certain indi-
viduals from the same business house occupied in the importing of pet ani-
mals; one of which animals, at least, had died of pneumonia. Since then,
he treated four other cases, three of them certainly pneumonia, the other
probably so. All of these were employes in the same shop. They had the
appearance of typhoid cases when first seen, and none of them had herpes.

III. Traumatic, or walking pneumonia. Under this heading the author
describes an interesting case, in which pneumonia appeared to follow an
injury, though the autopsy rendered it doubtful whether it was not an instance
of '* walking pneumonia," similar to walking typhoid.

Three Cases of Double Pneumonia Occurring Simultaneously in

one Family.

These cases, reported by Matheson {Brooklyn Med. Journal, 1888, 314),
occurred in the persons of three brothers, aged respectively eight, six, and
three and a half years. One case terminated fatally, and the autopsy revealed
pus and serum in the pericardium and the right pleural cavity, and complete
(•"tisolidation of the right lung. The left lung was red, swollen, inelastic,
and hepatized in portions, while other parts were still aerated, but had not
the appearance of lobular pneumonia. There were a few ounces of serum in
the left pleura. The symptoms were those of acute lobar pneumonia, were
alike in all three cases, and attacked all the boys on the same night. The
disease was bilateral from the first; an unusual feature in pneumonia due to
atmospheric influences. As regards the cause, there was no possibility of the
action of malaria or sewer gas; if of contagious or infectious origin, there
would have been a difference in the period of incubation in tin- three indi-
viduals; there was no Indication of diphtheritic or other zymotic influence.
The author believes that the irritating cause was the coal gas escaping in
large quantities from an old sheet iron stove in the room.

MEDICINE. 75

lN\ KsriOATIOXS ON THE MEANS OF DIFFUSION' OF THE

Tubercle Bacillus.

CORNET iMilnchener medlcinische Wochenschrift, 1888, No. 18, 308) has ex-
perimented with the dust obtained from the walls and floors of various dwell-
ings in which tuberculous patients had been ; inoculating guinea-pigs with it,
and carefully excluding all possibility of infection from outside sources. In
this way twenty-one rooms of seven Berlin hospitals were examined, and
bacilli found to have been present in the dust from most of them. Positive
results were also obtained with the dust from insane asylums and penitentia-
ries. The dwellings of fifty-three tubercular patients were investigated in
the same way, and the dust in the neighborhood of twenty patients found to
be virulent. It was the case with absolute regularity that the dust was always
virulent when the patient had been in the habit of spitting on the floor or in
a handkerchief; while it was never so when a spit-cup had been employed.

The author further found that smearing of tubercular material over quite
small wounds was sufficient to produce the disease. He tried the effect, too,
of the different medicines recommended for the treatment of tuberculosis, but
was unable to check or prevent the disease in the guinea-pigs which had been
inoculated; even the sending a half dozen of them to Davos was without
effect.

—

Ox the Determination of the Limits of the Heart by Percussion.

A review of the expressions of various authors, which Riess undertakes
(Zeitschr. /. klin. Med., 1888, xiv. 1), shows the greatest difference in opinion
with regard to the percussion boundaries of the neart; so much so that the
expression "heart dulness normal" has really no significance, unless we are
acquainted with the cardiac boundaries which the individual author adopts.
Many writers lay stress on the difficulty or impossibility of determining the
relative cardiac dulness, owing to the vibration of the sternum which percnsj.
sion calls forth ; and others describe special methods of investigation. 1!
has found that, as a rule, no special procedure is necessary, but that with
practice the determination of the actual size of the heart — i. e., the relative
dulness — may be determined by simple percussion, and he has confirmed his
observations by numerous post-mortem examinations. A great cause of the
uncertainty in fixing the normal heart boundaries is their reference to certain
variable lines: as the sternal, parasternal, and mammillary lines. The only
line which remains fixed, and which can be properly used is the midsternal ;
the continuation of the linea alba up to the jugular fossa; and from this all
lateral measurements should be made. Only in cases where the sternum is
deformed, as in scoliosis, can this line not be made use of.

In order to make practical employment of the method, it was necessary to
determine the distances from this base line in the normal condition ; and as
a result of his studies the author publishes two tables, each containing 100
cases, with measurements made on this principle. All were on males from
twenty to forty years of age, who were healthy so far as the heart was
concerned. The tables show a great uniformity in the measurements of the
different cases ; the averages being as follow

76 PROGRESS OF MEDICAL SCIENCE.

Distance from the jugular fossa}, 2J inches.
Distance from the middle line —

In 3d intercostal space, ] i I ' ^'g «

In 4th intercostal space, < ■ A 2 g "

These measurements agree fairly well with the few published ones made
on the same plan, though the actual breadth of the relative heart dulness is
somewhat less than certain authors have given it. To determine the relative
dulness the percussion should simply be stronger than that used for the abso-
lute dulness; but never need be painful, even to sensitive patients.

The Chemical Diagnosis of Diseases of the Stomach.

Klemperer (Zeitschr. f. klin. Med., 1888, xiv. 147-170) contributes a very
valuable critical and experimental paper, tending to clear away some of the con-
fusion and contradiction surrounding this subject. None of the color reactions
recommended are superior to methyl-violet ; hence their value as tests for
free HC1 in the gastric secretion will stand or fall with it. Authors were
generally agreed that it was conclusive, and Riegel's rich experience seemed
to place it beyond doubt, until Cahn and v. Mering, after careful experiments,
showed not only that neutral solutions, as well as free hydrochloric acid,
could turn methyl-violet blue, but that the reaction might be absent in the
presence of the free acid. They found that on adding the acid to carcinoma-
tous secretion, already containing a certain amount of it, methyl-violet still
failed to become blue. It was evident that free acid was present ; and the
failure of the test they attributed to the presence of large amounts of pep-
tone. Honigmann and Noorden showed, however, that it was not the pres-
ence of peptone which interfered with the reaction. They claimed that the
added acid was taken into combination by substances present in the carcino-
matous juice. This does not seem satisfactory to Klemperer, who could
rather believe that it replaces the organic acids in combinations with bases.
This substitution takes place, however, in secretions which are not carcino-
matous; and, besides this, investigations which the author has carried out
prove that in those which are, there is comparatively little of the organic-
acids. The contradiction, therefore, remained unexplained, that the gastric
secretion in many cases, especially of carcinoma, may contain HC1, and yet
not show the HC1 reaction.

Klemperer details some experiments which he made in order to remove
these contradictions, and to determine the actual value of the methyl-violet
test. He assumes that the bluing, when it does occur, is really due to the
presence of the acid, since other substances, which have been found capable of
producing it, are never present in the stomach in sufficient concentration to
give any reaction. As regards the question whether the absence of the bluing
proves the lack of free HC1, he says that the union of this amido substance —
methyl-violet — with HC1 is one of the weakest, and that all the organic bases
of whatever sort have a greater affinity for the acid than it has. Even those
which are so weakly alkaline that they give no reaction with litmus, will
prevent the bluing of the methyl-violet. The ptomaines are to be counted

MEDICINK. 77

among these, and the author has isolated that produced by the lactic acid
bacillus, and finds that it will break up or prevent the union of the acid with
the methyl-violet ; as will also peptotoxin, which is formed when albumen is
digested. The conclusion is, that bluing of methyl-violet occurs when the
HC1 is not united with other organic or inorganic bases.

The author then reports some experiments which show that the " exact
methods" hitherto employed, including that of Cahn and von Mering, for
the determination of free HC1, do not distinguish it from that in combination
with organic bases ; while the methyl-violet reaction only occurs when the
acid is absolutely free. The contradictions in the literature become, there-
fore, readily explainable if we remember that there is a difference between
the secretion and the presence of free HC1 ; and that there are numerous weakly
basic substances produced by the presence of albumen, or of mucin in the
iach, or by the action of bacteria there which unite with the acid; and
that we can only be certain that the HC1 is in a free state — and consequently
is capable of digesting — when it gives the reaction with methyl-violet.

The greatest practical question is whether the failure of the HC1 test is
pathognomonic of carcinoma. It is true that the reaction is seldom present
in this disease, yet it is doubtlul whether the acid is even diminished in quan-
tity, and sometimes it may be increased ; being combined with organic bases.
The persistence of the violet color, though supporting a diagnosis of carci-
noma, cannot be considered as decisive, especially when the disease is to be
distinguished from motor insufficiency with or without dilatation, or from
certain catarrhal conditions; since Klemperer has seen instances of these
affections, as have other writers, in which no bluing of the reagent took
place. The value, then, of this test is not so much in the diagnosis of any
particular anatomical change, as a proof of the absence of HC1, and as a
therapeutical indication.

Paralysis in Dysentery.

The following is an abstract of the conclusions drawn by Pugibet (Revue
de Med., 1888, 296) in an elaborate study of this subject, based on a tabular
collection of his own cases and of others taken from the literature : 1. Dys-
entery of hot countries may produce various nervous troubles, especially
paralysis. 2. Contrary to the general opinion, paraplegia is not the form
peculiar to dysentery and diarrhoea; but in both affections the most diverse
forms of nervous trouble may be observed. 3. Dysenteric paralyses have
often a sudden and nocturnal onset without icterus, are generally incomplete,
advance rapidly, terminate rather frequently in complete recovery, sometimes
last through life, rarely are fatal. 4. The nervous affection, usually symmet-
rical, may attack the motor, sensory, or mixed nerves; or even determine a
temporary glycosuria. 5. The muscles are attacked in a very capricious
manner. 6. The sensibility may be involved, but is often intact ; the elec-
trical contractility is normal or slightly diminished. 7. The paralyses are
not simply functional, but due probably to lesions in the anterior horns. 8.
The lesion is probably a capillary thrombosis producing atrophy of the nerve
cells. 9. The prognosis of the paralysis is usually good ; but that of the case
in general is grave, since the nervous lesions occur only in the most debili-
tated patients. 10. Dysentery of hot countries is often complicated by malarial

TOL. 96, HO. 1.— JCLT, 1888. 6

78 PROGRESS OF MEDICAL SCIENCE.

fever or cachexia. 11. Treatment is determined by the general condition of
the subject and by the nature of previous maladies.

Intussusception Relieved by Hydrostatic Pressure.

Butler [Brooklyn Med. Journal, 1888, 111) reports a case in a child of
three years, with constipation, tenesmus, slightly stercoraceous vomiting, cool
and moist skin, anxious expression, and a distended abdomen with a local-
ized sense of resistance, which was painful on pressure. The child was placed
on its face in the mother's lap and received an injection of about thirty-five
ounces of tepid water. It was then laid upon its left side, slept for six hours,
then voided the injection with a little fecal matter, suffered no longer from
pain and vomiting, and on the next day had a copious natural movement
and was well. The case shows the possibility of making an early diagnosis,
and of an easy and complete reduction depending upon this.

Hematuria Simplex in a Newborn Child.

Moyer {Chicago Med. Journ. and Exam., 1888, 271) reports a case of hema-
turia occurring in a small and delicate child ; one of twins. The bloody urine
appeared with the first evacuation of the bladder after birth, and continued
until the seventh day. There were no other symptoms except mild icterus
on the fifth day. Looking into the literature of the subject, the author can
find very few cases recorded, and usually no reference made to the matter,
though Goodhardt has something to say about it. Nephritis, stone, cancer,
tuberculosis, etc., are unfortunately the most common causes of the affection,
but it is well to remember that there may be a hematuria simplex.

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

SURGEON TO THE PHILADELPHIA AND GERMAN HOSPITALS; CLINICAL PROFESSOR OF GF.SI fn-r HI NAK V
SURGERY I.N THE UNIVERSITY OF PENNSYLVANIA.

Pulmonary Surgery.

L. H. Petit summarizes in L Union Medicate the discussion in the French
Congress of Surgeons upon the subject of the resection of ribs in chronic
empyema. Bouilly divides into five classes the cases in which such opera-
ti'His are to be considered: 1st, large cavities in which the lung, fastened to
the vertebral column by thick false membrane, is entirely and permanently
ipsed. In these cases the operation is useless and dangerous ; 2d, large
cavities in which the lung though condensed still preserves a slight vesicular
murmur ; intervention is then sometimes useful, particularly in young patients,
and when the cavity does not extend beyond the third rib ; •"><!, cavities from

SURGERY. 79

eight to twelve centimetres in diameter; these are those which present the
most favorable conditions for cure; 4th, simply fistulous tracts of greater
or less length ; if they are short and straight the results will probably be
good ; the prognosis becomes less favorable when the fistnlae are long and
tortuous; 5th, cases in which there are moderate-sized cavities with fistulous
tracts communicating with them ; in these the prognosis is favorable.

The surgeons who took part in the discussion agreed that the age of the
patient is of great importance, not only as to the immediate result, but also
as to the sequelae of the operation. Children recover much more rapidly
than adults or old persons, because the lung has more power of expansion
and the ribs more chances of reproduction. Ollier has pointed out two
dangers in this connection : if the ribs are resected too near their anterior
extremities their later development is interfered with, and great thoracic de-
formity may be produced. If the resection is subperiosteal, the great osteo-
genetic tendeucyof children, increased by the chronic inflammation, produces
hyperostoses which may necessitate secondary resection ; Leverat and Lyon
have observed such cases. If, therefore, the subperiosteal method of operating
is selected, which is really the easiest, it is well afterward to remove the peri-
osteum itself. Large cavities were thought by everyone to offer a contraindi-
cation to the operation, but for various reasons Le Fort thought that the ill
success in these cases was due to the prolonged drainage often used and the
great retraction of the lung. Bouilly refers it to the state of the pleural
wall, which, if it is thick and hardened, should be resected. Delorme
referred especially to tuberculous infiltration of the wall of the cavity the
nodules escaping the knife or curette of the operator, and to the diverticula
which form secondary cavities under the diaphragm, or between the lobes of
the lung. Kirmissox mentioned a case in which several operations had been
unsuccessful on account of the high position of the cavity and of the
extremity of the fistulous tract, which involved the summit of the lung.

The operative method should consist essentially in making a vertical inci-
sion, following as nearly as possible the greatest diameter of the cavity and
the direction of the fistulous tract and removing freely portions of the ribs.
The amount removed is determined largely by the dimensions of the cavity ;
according to Thiriar, it is better to take away two ribs too many than one too
few. It should be noted that, although Bceckel and Bouilly insisted upon
the above point, and attributed a want of success of their first operations to
the timidity with which they practised their resections, the rule does not
apply equally to the upper and lower ribs, the former yielding much less after
operation, and, therefore, producing a much less proportionate diminution in
the size of the cavity. Resection of the first rib is particularly useless and
dangerous. Resection of the middle ribs has a special danger to which
Berger called attention, he having lost a patient after removing portions of
the seventh, eighth, and ninth ribs, the operation being followed by great
ncea and death within four hours. He attributed this result to the in-
terference with the mechanical functions of the thorax, due to the loss of the
point of support given by these ribs to the diaphragm. Raclage of the wall
of the cavity should be as complete as possible, and it should be washed after-
ward with a ten per cent, solution of chloride of zinc. Disinfection of the
cavity is a necessary condition to success, although free washing was not ap-

80 PROGRESS OF MEDICAL SCIENCE.

proved by all speakers. Thtriar does not employ it, and Le Fort attributed
to pleural injections the fatal syncope which occurred in one of his patients.
Thirty-two cures were reported out of the total number of forty-nine cases
operated upon.

[In a paper published in 1884 by Dr. Bruejc, of Philadelphia, and the
writer, the following rules for this operation were formulated :

1. The portions of the ribs removed should be those between their angles
and their sternal attachments. Posterior to this they are less movable, and
are so close together that the difficulties of the operation are greatly increased.

2. Those ribs between the third and tenth should be selected which most
accurately overlie the cavity.

3. The number of ribs operated upon should be proportionate to the extent
of the cavity.

4. The length of the pieces excised should be proportionate to the depth of
the cavity.

5. The operation should be done aseptically and subperiosteal^, and when
so performed is almost without danger ; and even in cases where large por-
tions of ribs are removed is followed by no permanent loss of function in the
external respiratory muscles of that side.

The general conclusions at which we thus arrived, based upon the study
of the literature of the subject, and upon our experience with thirteen cases
of empyema treated in the University and Philadelphia Hospitals, were as
follows:

1. Those cases of pleural effusion which are most likely to become puru-
lent, and, therefore, to need operative treatment, are those occurring in persons
of lowered vitality, scrofulous diathesis, or who suffer from intercurrent
disease.

2. The diagnosis of empyema can only be made with absolute certainty by
puncture and inspection of the fluid. This method of examination need not
be delayed for fear of favoring the purulent transformation of a serous fluid,
if proper aseptic precautions are observed.

3. In young children, one or two aspirations will often suffice for a cure.
If these fail, simple incision of the chest without the introduction of the
drainage tube is often all that is requisite.

4. In older children and in adults, it is proper to aspirate once ; but recovery
not resulting promptly, a large drainage tube should be inserted at the most
dependent point.

5. If, after this, drainage is still imperfect, as shown by the fetid character
of the discharge, a second opening should be made, and a tube carried
directly across the base of the cavity.

6. If, after a suitable delay (from two to four months), there is no disposi-
tion to permanent closure of the suppurating cavity, but if the lung has
expanded sufficiently to indicate that it is capable of further descent, it would
then be proper to facilitate its expansion and the obliteration of the cavity,
by removing certain portions of the affected side.

7. If thorough drainage is accomplished, the use of disinfectants by intra-
thoracic injections is rendered unnecessary, unless a stimulant to the granu-
lating Riirface is required.

8. In cast's in which the lung is at the bottom of the chest, and bound fast

SURGERY. 81

to the diaphragm, or in which it has heen so atrophied prior to aspiration
that there is n<> possibility of reinflation, or in which it is occupied by a tuber-
culous or an inflammatory infiltration, this operation is contraindicated.]

Foubet (Archives Gen. de Med., Oct. 1887) has reported the results of 80
operations upon the lungs. In 7 cases of tuberculous cavities, in which an
incision was made either with or without resection of the ribs, there were 5
deaths, 1 alleged recovery, and 1 case in which life was prolonged. In 14
cases of abscess of the lungs, there were 9 cures, and 5 deaths ; in 18 cases of
gangrene of the lung, there were 7 deaths, 9 cures, and 2 cases reported as
improved; in 12 cases of bronchiectasis, there were 4 cures; in 29 of the
successful cases the indication for operation was the presence of hydatids.

Mk. A. Pearce Gould [The Lancet, Feb. 11, 1888) reports 4 cases of
Oestlander's operation for thoracoplasty, in three of which the patients were
remarkably improved, the last one dying suddenly the day after the opera-
tion. Mr. Gould calls especial attention to the following points :

1. Carefully explore the cavity to be treated either before the operation, or
as a first step in it. All the ribs lying in the wall of the empyema must be
excised ; the surgeon must, therefore, begin by determining the vertical and
the antero-posterior extent of the cavity. This may be done by enlarging
the fistula?, and opening and passing in the finger.

■1. A single vertical incision is all that is necessary, and should extend
through the skin and muscles down to the rib. When the cavity extends far
back toward the spine, it will be found convenient, after removing the front
portion of the rib in the usual way, to remove the posterior part from the
inside, peeling the thickened periosteum off" the bone, and applying tne
cutting forceps from within the chest.

•".. When the ribs are lined, as is often the case, by dense cicatricial tissue
for an inch or more in thickness, this, too, must be entirely cut away with
scissors. Mr. Gould believes that full success is only to be anticipated where
all physical obstacles to the entire obliteration of the cavity have been
removed. The sooner it is carried out the better, for marked exhaustion or
serious visceral disease renders the operation too dangerous to be recom-
mended.

Rectal Insufflation of Hydrogen Gas in the Diagnosis of
Intestinal Wounds.

Dr. N. Senn, in a remarkable paper on the above subject (The Medical News,
May 26, 1888), comes to the following conclusions:

1. The entire alimentary canal is permeable to rectal insufflation of air or
gas.

■1. Inflation of the entire alimentary canal, from above downward, through
a stomach tube rarely succeeds, and should, therefore, be resorted to only in
demonstrating the presence of a perforation or wound of the stomach, and for
locating other lesions in the organ or its immediate vicinity.

3. The ileo-csecal valve is rendered incompetent and permeable by rectal
insufflation of air or gas, under a pressure varying from one-fourth of a pound
to two pounds.

\. Air or gas can be forced through the whole alimentary canal, from anus

82 PROGRESS OF MEDICAL SCIENCE.

to mouth, under a pressure varying from one-third of a pound to two and a
half pounds.

5. Rectal insufflation of air or gas, to be both safe and effective, must be
done very slowly and continuously.

6. The safest and most effective rectal insufflator is a rubber balloon, large
enough to hold four gallons of air or gas.

7. Hydrogen gas should be preferred to atmospheric air or other gas, for
purposes of inflation in all cases where the procedure is indicated.

8. The resisting power of the intestinal wall is nearly the same throughout
the entire length of the canal, and, in a normal condition, yields to a diastaltic
force of from eight to twelve pounds. When rupture takes place, it either
occurs as a longitudinal laceration of the peritoneum on the visceral surface
of the bowel, or as multiple ruptures from within outward at the mesenteric
attachment.

9. Hydrogen gas is devoid of toxic properties, non -irritating when brought
in contact with living tissues, and is rapidly absorbed from the connective
tissue spaces, and all of the large serous cavities.

10. The escape of air or gas through the ileo-caecal valve, from below upward,
is always attended by a blowing or gurgling sound, heard most distinctly over
the ileo-caecal region, and by a sudden diminution of pressure.

The Influence of the Kidney in Producing Vesical Symptoms.

M. GuYON reports [Annales des Maladies des Org. Gen.-Urin,, April, II
an interesting case of a patient, forty- two years of age, with a history of
repeated attacks of nephritic colic, and of three lithotripsies, all of which he
had borne well. In August, 1887, he was attacked with sharp pain in the
region of the right kidney, and afterward with a series of nephritic colics ; the
renal pain increased ; he walked bent almost double, and finally developed
increasing and urgent frequency of urination both by day and night.

On his admission to the hospital he urinated every four or five minutes, and
urination was accompanied by sharp vesical pains. The pain began before
the beginning of urination, and was severe again at the end of the act. In
December the urine became bloody and remained so. There was little or no
pus in the urine. Rectal examination disclosed a hard mass at the vesical
end of the right ureter. There was no true cystitis. Treatment of various
kinds gave no relief. The patient died on December 23d. The autopsy dis-
closed inflammatory lesions of the end of the ureter, renal calculi, dilatation
of the right kidney, and disappearance of the cortical substance.

Imperforate Anus with Rectal Diverticulum.
Dr. Hildebrandt {Deutsch.'Zeitschr. fur Chirurgie, Feb. 1888) reports a
case of imperforate anus and rectal diverticulum. The anal point was marked
by a few folds of skin, through which the sphincter could be felt. An < \
ploratory incision was made, but without result, as there was no indication of
a rectum. An artificial anus was then made in the left iliac region. An
enormously distended gut was found, stitched to the belly wall and incised.
The patient was a boy baby, three days old. He was brought back in sewn
weeks, with a well-marked diverticulum beginning at the lower end of the

SURGERY. 83

descending colon, at the seat of the artificial anus. It was ligatured and cut
off, and measured fourteen centimetres in length.

Open Incision in Why Neck, Contracted Knee, and Talipes Varus.

Dr. E. H. Bradford reports (Boston Med. and Surg. Journal, March 22f
1888) the case of a boy aged eleven years, with anterior torticollis. A free
incision was made about one and one-half inches above the clavicle for the
entire width of the insertion of the sterno-mastoid ; the belly of the muscle
was thoroughly divided, as well as some contracted fascia beneath the muscle.
In a second case, in a girl aged fourteen years, the same operation was per-
formed. In both, the wound healed by first intention, and the results were
entirely satisfactory. The advantages of subcutaneous tenotomy in these
cases are the absence of scar and the lessened danger of the operation ; the
disadvantages are, the difficulty of dividing thoroughly all the fibres of the
fascia, and, in case of imperfect division, the danger of wounding important
vessels, which results from an attempt to make deeper incisions.

In the open method, the surgeon can clearly view before dividing the resist-
ing point. If the operation is aseptic the scar is very slight, and there is no
suppuration. The incision may be made in the hollow above the clavicle,
and parallel with it, leaving a linear cicatrix, which is scarcely noticeable.
The thoroughness of the division of the contracted parts lessens the time
required for mechanical after-treatment.

Dr. Bradford also reports successful cases of resistant club-foot, and of
spastic paralysis with contraction of the hamstrings, successfully treated by
open incisions.

Rectal Carcinoma.

Dr. Otto Hildebrand (Deutsche Zeitschrift fiir Chirurgie, Feb. 1888),
writing on the subject of statistics of rectal carcinoma, asserts that no special
cancer microbe has yet been discovered. He knows of no satisfactory way
of accounting for the great frequency of intestinal cancer at the lower end
of the bowel. He does not think that hemorrhoids and the irritation of fecal
matter can act as etiological factors. The large majority of cases occur
among persons from fifty to seventy years of age, though Czerny observed a
rectal cancer in a girl of nineteen which was so extensive that an opera-
tion was impossible. It affects almost twice as many men as women. In
187 cases of Billroth, Fischer, Kocher, Czerny, and Konig, 123 were men
and only 64 women. In very many of these cases the carcinoma was annu-
lar, a small number were flat, and in several instances they formed tumors
projecting into the calibre of the gut. In many cases the peri-rectal lym-
phatic vessels and glands were involved. Of 69 cases, 15 were too far ad-
vanced for operation. Of the 54 operated upon, there was a failure to remove
the entire mass in 13. He concludes that half the cases operated upon had
an involvement of the lymphatic glands, and that rectal carcinoma is rela-
tively less malignant than mammary cancer. He takes exception to Wini-
warter's statement that the inguinal glands are primarily affected as he has
observed them once so only, though he has frequently seen the rectal glands
affected. Henke also contradicts Winiwarter. Of the cases cited 10 were

84 PROGRESS OF MEDICAL SCIENCE.

metastatic; deposits were found as follows: in the liver 7, spleen, kidneys,
lungs, ovaries, each 2, mediastinal glands, ileum, pylorus, and skin, each 1
case. Excision should be invariably practised as the only remedial measure,
except when there is no promise of a successful healing. Proper preparation
is important, and this consists mainly in emptying the bowel. It is very im-
portant to avoid irritation of the wound by early evacuations or desire to go
to stool. In cases of extensive involvement of the bowel extending upward
from the anal margin, it is best to excise the coccyx, thus affording more room
for injection and operation. In some cases adherent peritoneum was excised
while in many others it was extensively pulled off* the growth. Wounds of
the peritoneum were immediately sutured, a drainage tube being introduced
in the intestine. It was considered very important to keep the patient in a
half sitting position after the operation. The neck of the bladder wan
wounded three times and the seminal vessels and prostate each once.
Wounding of the urethra was treated successfully by retaining a catheter in
the urethral canal. Wounds of the neck of the bladder were treated by
suturing the vesical mucous membrane to the external wound. All access-
ible glands were removed in every case, and at the end of the removal the
gut was drawn down and united to the external wound. Care was always
taken to have a circular union of the skin and mucous membrane. The
median incisions were, as a rule, not sutured so as to prevent a retention of
excretions. Konig prefers union at once with deep sutures.
In 57 operations death resulted as follows :

1. Collapse

2. Septic infection

3. Fatty heart

4. Perforating peritonitis not due to the operation

5. Unknown causes (no infection, no loss of blood)

1
3

He ascribes the increased success in these cases during the last few years
to the introduction of iodoform dressings. Tabulated statistics are given to
show that in a proportion of cases good function of the bowel may result after
the operation, and that it is likely to improve with time. He concluded that
the results that usually follow excision do not form a pleasant picture ; that
the mortality of the operation is still high; that definite healing is a rather
rare occurrence; and that the function after the operation is, as a rule, imper-
fect. More care should be exercised in the selection of cases for operation.

Treatment of Fracture of the Patella.

Prof. Antonio Ceci (Deutsch. Zeit. fiir Chirurg., Feb. 1888) details as
follows the various methods of treatment of patellar fracture:

1. The use of Malgaigne's hooks, which, he thinks, is mistakenly considers!
as among the bloodless operations.

2. The tendon suture of Volkmann (18GS), which consisted in passing a silk
suture through the skin ami <piadriceps tendon, and skin and tendo-patelhe-
Thi- i- then drawn tight and tied, with tin- knee extended and the fragments
approximated. A plaster dressing is then applied, upon the setting of which

SI -RGERY. 85

an opening is made, and the ligature and suture cut and withdrawn. In later
years Volkniann is said to have preferred a silver suture.

\ -throtomy and suture of the broken ends, after Lister (1876), either
through a longitudinal or transverse incision, aided in old fractures by
tenotomy of the quadriceps (Macewen), or by various kinds of myotomy.
( »r, lastly, with section and upward displacement of the tuberosity of the
tibia (Bergmann), for the purpose of approximating the broken fragments.

4. Puncture of the haiinarthrosis, after Schede (1877), either alone or
accompanied by washing out the joint with carbolic acid solution and subse-
quent massage, so as to dissolve coagula.

•">. The peri patellar suture of Kocher, consisting of a silk thread passed
above and below the fragments, through either a transverse or longitudinal
incision (preferably the latter). The ends are drawn together and twisted
over a gauze cylinder. The knot is buried in the wound, and the skin sutured
over all. Konig does a similar operation with catgut.

The author's operation, consisting of a subcutaneous buried suture,
demonstrated by him on the cadaver on May 25, 1887, before the Academy
I Iedicine at Padua, and performed on two actual cases a few days later
May 28th and 30th).

In his first paper the author claimed that his operation was indicated in new
cases, that in old cases freshening of the fragments was unnecessary, that the
wire probably caused a beneficial stimulus, and that it was prophylactic
against recurring fracture.

In his second paper he added that his operation, being applicable at once,
reduced the chances of degeneration and shortening of the quadriceps, and
made it possible to secure use of the knee in six to eight days. Another
advantage of his operation is that in comminuted fractures it bunches the
fragments and prevents all longitudinal displacement, as the wire passes sub-
cutaneously through the tendons above and below the patella, close to it3
margin. He reports five cases in detail. They were all successful. It was
possible, months after the operation, distinctly to feel the line of union between
the fragments, and feel the wire and knot through the skin. He exhibited his
third case to the Academy at Vienna eighteen months after operation. The
gait was perfect. Three of the patients were aged (69, 70, and 65 years), and
in one there was a bad splintering of the lower fragment.

He claims the following advantages for his operation over all others :

1. The general applicability of his suture, no matter how great the number
of fragments.

A mechanical union of the fragments, affording efficient and permanent
resistance.

3. The subcutaneous method, and the resulting rapid and complete union
of the superficial and deep soft parts, completed in from four to eight days.

4. Removal of the dressings as early as the fourth to the eighth day, after
which the joint requires neither immobilization nor compression.

The practical significance of these advantages appears more plainly after
consideration of the causes of impairment or loss of joint function after
patellar fractures. These are divided into three categories:

1. The nature of the callous formation.

86 PROGRESS OF MEDICAL SCIENCE.

2. The fibrous growths between the ends of the fragments and the intra-
and extra-articular fibrous thickenings.

3. Atrophy and impairment of function of the muscles, especially the
quadriceps.

If fibrous bands curl in between the broken fragments, and thus prevent
bony union, the wire suture proves sufficiently strong to hold the fragments
together. This unites the patella functionally if not actually. The passive
motion possible often in from four to eight days, and the active movements
that the patient can begin almost at the same time, are likely to prevent intra-
and extra-articular thickening. Puncture of the joint, according to Schede's
method, is not necessary in this procedure, as the needle puncture admits of
the exit of the blood, which can also be accelerated by massage during and
after the osteoraph. The same method may be employed in fractures of the
olecranon, and is then simpler in its application. It is very important in
this procedure to have the external wound as small as possible. Experi-
ments on dogs have repeatedly shown that the subcutaneous metallic suture
is harmless. In the third case of his five there was a second operation on the
same joint, and the two subcutaneous peri-patellar wires could easily be felt,
and gave rise to no inconvenience whatever. It makes little or no difference
whether this operation be done immediately or some days after the injury.
He believes that in cases of severe injury it is best to wait several days, so as
not to aggravate the existing troubles by a possible mechanical irritation.

Luxation of the Fibula.

Hirschberg [Archiv far Klinische Chirurgie, vol. xxxvii.) summarizes as
follows the symptoms of luxation of the head of the fibula :

a. Subjective: Impossibility of walking or standing; complete extension
of knee; only moderate interference with flexion ; radiating pain, with numb-
ness of the leg.

b. Objective: Widening of the knee; abnormal forward projection and
arched tension of the biceps tendon in anterior luxation, spasm of the biceps
in posterior luxation ; slight adduction of the foot secondary to abduction of
the entire fibula; absence of the head of the fibula from its proper place; the
presence of the head near the ligamentum patella;, or at the back of the tibia,
at either of which places it is easily recognized by the insertion of the biceps.

The writer gives a copious bibliography of the subject.

Mr. Ashley Leggett reports {The Lancet, March 31, 1888) the case of a
patient who, while playing football, slipped, and fell with his right leg doubled
underneath him, so that he sat, as it were, upon the outside of his own foot.
The pain at the time, and afterward, was very severe. On examination, the
head of the fibula was found to be dislocated forward, being plainly seen and
felt beneath the skin. Immediately behind and above it there was a distinct
hollow about an inch in diameter. The tendon of the biceps was very tense.
The muscles on the upper fourth of the anterior part of the injured leg INN
apparently flattened, and the head of the bone was approximated to the
tubercle of the tibia. During etherization, the leg being semi-flexed, the
patient kicked out strongly, and the head of the bone slipped back into place.
The leg was put up in plaster of Paris, which was removed in four days, there

SURGERY. 87

being no effuaion or swelling about the joint. The case is interesting, first,
on annum at its rarity (Erichsen reporting but one such case) ; secondly, on
int of tlic peculiar but ready way in which it was reduced; Erichsen
was unable to reduce his, owing to the tension of the biceps tendon, and a
similar failure occurred in a case of Mr. Annandale's, which the writer had
seen ; thirdly, because the usual accident, after such falls, is subluxation of
the knee-joint, with displacement of one or other of the semilunar cartilages.

Arthrectomy.

Dr. Paul Sendler reviews (Deutsche Zeit&chrift fur Chirurgie, February,
1888) the relative merits of resection and arthrectomy of the knee, holding
that the preference of the day is already practically in favor of the latter.
The most important point in favor of arthrectomy is, that shortening is prac-
tically excluded. In fact, he has not yet observed any even in extreme cases
of ossific tuberculosis. In operating with the intention of securing ankylosis,
it is generally agreed that the particular method of opening the joint is of
little moment so long as the parts to be investigated are sufficiently exposed
to view, but he holds that the reverse is true if motion is to be attained. If
the object be to secure ankylosis, Volkmann's incision should be used, but if
a false joint is to be made, he prefers Konig's. In these latter cases, he has
seen spontaneous slight voluntary movements by the patient as early as the
third week after the operation. In such instances, they continued these
movements after leaving the bed, and were discharged with a very movable
joint and without having been subjected to electrical treatment and massage.
A longitudinal incision is preferable, it always being possible to add a trans-
verse incision if the joint is sufficiently diseased to make this necessary and a
new joint impossible. He reports in detail fifteen knee operations performed
on thirteen patients during the last three years. Four of these, including
one puncture, were arthrotomies, while the others were either partial or com-
plete arthrectomies (two double) for tubercular disease. Healing, as a rule,
was without reaction, and, as far as possible, union was primary. He con-
eludes :

I. A movable joint is to be preserved: a. After puncture and simple arth-
rectomies. b. In all partial arthrectomies in cases of local synovial tuber-
culosis.

II. The attempt to preserve the mobility of a joint is justified: a. After
arthrectomies in cases of synovial tuberculosis, if of not too high a grade and
without involvement of bone. b. In the lighter forms of tuberculosis, even
if small pieces of bone have to be removed, c. At least on one side where
there is tuberculosis of both knees.

III. Ankylosis with the knee extended is to be attempted : a. In severe
general synovial tuberculosis, b. In the grave ossific varieties.

IV. The line of incision for the opening of the joint depends upon the
result desired. If mobility is to be preserved, it is necessary to select a
method that will not interfere with continuous and efficient extension ; but
if ankylosis be desired, it is best to select that method which is most conve-
nient in each case.

88 PROGRESS OF MEDICAL SCIENCE.

Mr. H. H. Clutton believes (The Lancet, April 21, 1888) that as excisions
are becoming more and more rare, surgeons should pay increased attention to
the operation of arthrectomy. He strongly advocates its early performance
and urges that in case of joint disease as soon as it is clearly demonstrated
that the trouble has not been arrested in its progress by an apparatus which
gives absolute rest, the operation of arthrectomy may be fairly looked upon
as one for consideration. Doubtful cases in which it is difficult to say whether
the disease is progressing or not, should, of course, be left for another month
or two until it appears probable that recovery by rest alone is not likely to
ensue for any considerable length of time. He does not believe that we
ought ever to attempt to obtain a movable joint, but ought rather to aim
at procuring just such a condition of the articulation as is seen in sponta-
neous recovery after perfect rest — i. e., freedom from pain and tenderness,
absence of all swelling, and, as a general rule, ankylosis. You thus obtain
the same result in as many months as it would otherwise take years to accom-
plish, and, moreover, very materially lessen the chances of a subsequent
excision. In performing the operation, the joint being widely opened all the
synovial membrane which is obviously diseased is removed with scissors or a
scalpel. As a general rule, there is a very distinct interval between the gela-
tinous synovial membrane and the capsule, which serves as a guide to the
operator during this dissection. The capsule and fibrous tissue surrounding
the joint is retained so that it may again be united after the operation is com-
pleted. The articular cartilages, the ligaments, and the bones are then care-
fully examined, and such parts as are diseased are removed by the gouge or
sharp spoon. Great attention is paid to providing for perfect drainage, and
to the union of all the fibrous tissues and the soft parts which have necessarily
been divided. Mr. Clutton believes that by arthrectomy we can shorten many
cases of joint disease by taking them in their early stages, and cau often avoid
the more radical and unsatisfactory method of excision.

Wound Treatment.

SchLjECHTER (Deutscfie Zeitschrift fur Chirurgie, Feb. 1888) calls attention
to the great need for absolute cleanliness in the treatment of wounds, and
emphasizes the important practical point that antisepsis without cleanliness is
not a sufficient guarantee against infection. He details the various antiseptics
which have, from time to time, been advocated and then dropped out of use,
and dwells upon the irritating influence upon the tissues which many of them
possess.

I'll!-. Ti:r.ATMKNT OP GONORRHCEAL Khkim \ nSM BY ELECTRICITY.

Dr. Photiai.k- n -ports (GazetteHebdom.de Wed. et de Chirurg., May 4,
1888) a case of a man who Ktffered severely with synovitis, arthritis, and
myositis with each successive attack of gonorrhoea. With t lie hist OM the
suffering was so great that all varieties of treatment had failed. A farad ic
current was applied forsix minutes to the knee-joint, six minutes to the band,
and four minutes to the nape of the neck. Its intensity was gradually aug-
mented until the patient could no longer bear it. The relief was immed

OTOLOGY. 89

ami striking, the resolving effect manifesting itself from the first moments
of treatment. The exudation became absorbed, the normal contour of the
parts returned, and after twenty-four seances, made during thirty-six days, the
patient no longer felt any of the stiffness of the knee-joint, which had not
left him since his first attack six months previously.

OTOLOGY.

UNDER THE CHARGE OF

CHARLES H. BURNETT, M.D.,

PftOraBOR Or OTOLOOY IN THE PHILADELPHIA POLYCLINIC AND COLLEGE FOB GRAM'ATES IN MEDICINE, ETC.

Diseases of the Ear or General Diseases.

Diseases of the ear are frequently dependent upon general diseases. In
addition to the well-known influence of tuberculosis, eruptive fevers, syphilis,
Dr. Wolf (Section of Otology, Wiesbaden Congress, September, 1887) insists
upon the effects of pneumonia in the production of acute otitides. Rheuma-
tism may attack the joints of the auditory ossicles. Endocarditis, in one case
observed by Wolf, produced a thrombosis in the internal auditory artery.
Chlorosis, amemia, metritis, tobacco, lead, and mercury poisoning frequently
cause affections of the labyrinth.

Treatment of Boils in the Ear.

Dr. GROSCH {Berliner klin. Wochentchrift, April 30, 1888) has found that a
solution of acetate of alumina, one part to four of water, will act most promptly
in aborting furuncles in the external auditory canal.

The canal should be filled with the above solution every hour, and a piece
of cotton placed in the meatus to retain the fluid in the canal. The pain is
said to be partly quelled in four hours, and entirely removed in eight hours,
by this treatment.

Its action is explained thus by Dr. Grosch : The acetic acid possesses the
property of distending the tissues, without destroying their continuity, and also
of penetrating deeply into them. The loosening thus brought about produces
the desired relief to pain by removing the pressure from the terminal nerves,
and, with the disinfecting power of the solution, brings about the desired cure
by destroying the elements of infection.

Airal Epilepsy Compared with other Epilepsies.

If. ItoTJCHERON (Societe Frangaise d' Otologic el de Laryngologie, April 27,
1888), in presenting a paper on the above subject, characterizes this form of
epilepsy as consecutive to a direct action upon the auditory nerve. He quotes
Noquet, who observed a mute affected with tinnitus and epileptic attacks, who
was cured by Politzer's inflation of the tympanum. In this form of epilepsy,
the irritation is conveyed to the bulb, which is a true epileptogenous centre.

90 PROGRESS OF MEDICAL SCIENCE.

The latter can be excited by irritating any of the nerves communicating with
the bulb, viz., the trigeminus, the pneumogastric in all its portions, and hence
the variety of the origins of vertigo. Certain epilepsies can originate from
compression of the cerebral convolution where the acoustic nerve originates.
Epilepsy may be due to alcoholism, to the presence of ptomaines originating
in the residues of nutrition, to disturbances in the secretion of urine, and to
the presence of microbes. The intensity of the attack depends on the forms
of excitation and the facility of excitability. Then arise phenomena of
multiple irradiations of great, medium, or feeble intensity, whence come
disturbed equilibration and loss of memory. There is no difference in the
epileptic attack from these various causes. Diagnosis is impossible without
searching for the cause, and it must be remembered that all epilepsies are
symptomatic.

Tubercular Syphilide of the Auricle.

Dr. Robert Barclay, of St. Louis, Mo. [Journal of Cutaneous and Genito-
urinary Diseases, March, 1888), gives an account of a tubercular syphilide of
the auricle, becoming serpiginous, and attended with ulceration and seques-
tration of the cartilage of the concha, tragus, and canal. This was followed
by membranous atresia and deafness, but relieved by an operation. The
latter was as follows : First, an incision was made into what was supposed to
be the seat of the normal meatus. This gave vent to retained sero-purulent
matter, accompanied by cakes and flakes of pus, desquamated epithelium and
other decomposed tissue. After cleansing and insufflation of boric acid and
calendula, a tightly rolled tampon of absorbent cotton was inserted. The
next day the tampon was removed, and the discharge found to be diminishing.
A scalpel then was used to widen the canal in a search for the membrana
tympani, which was easily found, and seen to be spotted with granulations.
The next day the discharge was observed to be further diminished, the
opening, however, showed a tendency to contract. Boric acid powder was
insufflated, and another cotton-wool tampon inserted. Hearing for watch
■fa. Same conditions and treatment the next day ; and for two days more.
The opening showed less and less signs of contracting, but upon neglecting the
treatment prescribed for him, another form of dilatation, viz., first, soft-rubber
tubing, and then a section of a hard-rubber canula, was used. This seemed
to promise a cure, if his habits, which were intemperate, did not interfere
with his proper attention to directions.

Ivory Exostosis removed from the External Auditory Canal.

Mr. George Stone (Liverpool Medico- Chirurgical Journal) has reported
the growth of an exostosis in the auditory canal, and its removal, similar to
a case observed by your reporter, an account of which was presented by hira
at the last meeting of the American Otological Society, July, 1887.

Instead of boring these growths with several small canals and thou uniting
them, it has been found by your reporter {loc. cit.), and by Mr. .Stone, that a
few taps with a small chisel driven by a hammer will knock the exost<»is from
its attachment. When the latter is very broad, and the growth acuminated
or conical, this method of cutting could not be applied to the bone, but would

OTOLOGY. 91

be required to be applied at the apex of the cone first, and then, when it is
removed, to successive lower layers of the exostosis.

Tuberculosis in the Ear.

Dr. Habermaxn has lately examined, post-mortem, eighteen ears of tuber-
culous subjects, in whom either otorrhcea or deafness without active discharge
had btvn observed during life, and in nine of these he could demonstrate the
presence of tuberculosis in the auditory organ. In one instance there was
found in the left auditory apparatus of a child, a year and a half old, tubercu-
losis of the entire middle ear, extending from the isthmus of the Eustachian
tube to the mastoid antrum, without perforation of the membrana tympani.

In another case of tuberculosis, in a man, thirty-eight years old, in whom
tuberculosis of the ear was observed a year and a half before death, the post-
mortem examination revealed extensive tuberculosis of the cochlea, in the
internal auditory canal, and in the superior semicircular canal, while the other
semicircular canals and the vestibule were destroyed by caries. There were
signs in the labyrinth in this case of tuberculous ravages in childhood, in a
measure filled up by connective tissue. There was also found a tubercle, the
size of a lentil, at the mouth of the aquaeductus vestibuli. — Prager med.
Woehenschrift, March 7, 1888.

Iodol in Otitis Media Purulenta.

Pcrjesz {Centralblatt fi'i r die gesammte Tfierapie, April, 1888) has employed
iodol in eighteen cases of otitis media, some of which were chronic, and
others acute, and has been well pleased with his results. In the acute forms
the discharge ceased in a few days (as it does under the use of many other
drugs, Rev.), and in the chronic form in a comparatively short time. The
iodol was applied once daily, and, notwithstanding its slightly irritant proper-
ties, was well borne. In two cases it had to be stopped. Iodol does not seem
to be nearly equal to iodoform, however, and, notwithstanding the disagree-
able odor of the latter, the former will not readily supplant it.

Photoxylin Solution as a means of closing Persistent
Perforations in the Membrana Tympani.

L. Guranowski (Archiv f. Ohrenheilkunde, Bd. 26, S. 163, 1888) has
employed a twenty per cent, solution of photoxylin, in five cases of persistent
perforation in the membrana tympani, to close the perforation. The ear is
first syringed with a boric acid solution and then dried with absorbent cotton.
Then, under good illumination of the fundus of the auditory canal, the edges
of the perforation are painted with the aforesaid solution. This dries in ten
minutes, leaving a pellicle over the perforation. A second application is now
made toward the centre of the former perforation from the periphery, and
then a third, and others, until the entire perforation is covered with a good
layer of photoxylin. The next day this new membrane will be found tight,
transparent, and resistent to pressure from a probe, and to inflations by the
Eustachian catheter. Guranowski also has applied this solution to flabby
cicatrices, which become firm, after having been movable at each act of
swallowing.

92 PROGRESS OF MEDICAL SCIENCE.

The Use of Lactic Acid in Chronic Purulent Otitis Media.

Dr. Victor Lange {Ibid.), encouraged by the use of lactic acid in tuber-
cular laryngitis, has employed fifteen to thirty per cent, solutions of lactic
acid in uncomplicated, chronic purulent otitis media. Stronger solutions are
used as the tolerance of the ear increases. The drug is applied either on cotton
pledgets soaked with the solution, or a few drops are instilled into the ear.
The stronger solutions are suitable for those cases in which considerable
thickening of the mucous membrane and prominent granulations are present.

The treatment is soon followed by a diminution of the secretions and a
disappearance of bad odor. Small, soft, and vascular granulations shrivel
very soon, but tough ones resist for some time, even concentrated solutions of
lactic acid. This acid seems to possess no haemostatic properties, nor is it
adapted to the treatment of acute forms of otitis.

Surgical Removal of the Malleus.

Dr. Stacke, of Erfurt (Archivf. Ohrenheilkunde, Bd. 26, S. 115), contributes
the history of ten cases of this operation, the first being performed in June,
1885. Thi3 operation is indicated in two classes of ear diseases, viz.: 1. In
chronic otorrhcea, from suppurative otitis media, with disease of the malleus
and incus. 2. In chronic catarrh of the middle ear producing deafness.

Regarding the first group, as the author says, there can be hardly any differ-
ence of opinion. For, if the surgeon is justified in resecting a tuberculous
hip-joint, excision of the hammer bone in caries of the same, is the only
rational procedure.

The subsequent state of the hearing should not be considered, if the opera-
tion of excision is indicated upon surgical grounds of expediency. "Even
if an ear retaining still some power of hearing, should become entirely deaf
in consequence of the operation, the operation would still be justifiable on
purely surgical grounds, because by the excision of a carious nidus the danger
of loss of health, and life too, is removed."

The hearing, however, is often improved, because by the excision of the
diseased malleus and incus, which often bind the stapes down firmly in the
oval window, the stapes is freed, and its vibration with sound waves, once
more permitted.

In the second class, cases of deafness and tinnitus from chronic aural catarrh
without perforation and otorrhcea, the operation is undertaken simply to
relieve the deafness and tinnitus. When the deafness is largely due to fixa-
tion of the malleus by adhesion at the promontory, excision will be followed
by hearing of twenty to twenty-five feet for whispers. It can be set down as
an axiom that in such cases, if the sound conductors and the perceptive
apparatus are normal, excision of the malleus will be followed by a hearing power
of twenty-five to thirty feet for whispered words.

We regret we cannot enter more fully into the details of the cases and the
operation. Dr. Stacke's operations were performed with the patient under
anaesthesia. The mode of illumination is not given. In this country the elec-
tric lamp, specially arranged for the surgeon's forehead, is used, as planned
and recommended by Dr. Samuel Sexton, of New York.

OTOLOGY. 93

I \sf of Thrush in TH1 Middlk Ear.

P«OF. Valentin, of Berne [Ankimf. Ohrenheilk., Bd. 2t'>, 81, Feb. 1888),
reports a case <>t' thrush in the middle ear of a girl nine years old. The same
aphthous growth extended over the mucous membrane of the hard palate,
pharynx, and Eustachian region of the affected side. Beneath these
patches the mucous membrane was disposed to bleed. The nares were free.
Beneath the microscope the false membrane was shown to be composed of
manet of pavement epithelium, numerous cells of thrush, with characteristic
mycelium.

The left ear emitted a peculiarly disagreeable odor. The auditory canal
was filled with cheesy masses of the fungus, easily syringed out. The lower
part of the membrane was destroyed. The fungus was found growing in the
middle ear. The regrowth was obstinate on the hard palate, but disappeared
entirely and permanently from the ear, under the internal administration of
iodide of iron and malt, and the local use often per cent, solution of sulphate
of copper, which Prof. Valentin prefers to alcohol or corrosive sublimate as
■ destroyer of fungi in the ear.

Bomb Rare Cases of Disease of the Middle Ear, Complicated by
Intracranial Lesions.

Dr. E. Schmiegelow, of Copenhagen (Archiv fiir Ohrenheilkunde, Bd. 26,
Feb. 1888), reports several cases of the above-named nature.

The first case was one of primary disease of the base of the skull and the brain,
either hemorrhagic or neoplastic in nature. This was followed by secondary
necrosis of the petrous portion and of the temporal bone, and purulent soft-
ening of the temporal lobe of the brain. Subsequently a chronic purulent
otitis media became established. Acute leptomeningitis followed.

The history of the patient showed that in his work he had often received
blows and knocks on the head. He had suffered for years with a chronic
non-purulent otitis media. Suddenly, intense neuralgia of the trigeminus of
the right side, in all three of its branches, set in. This was soon followed by
facial paralysis of the same side, choked disk and optic neuritis, all showing
that a lesion had occurred at the base of the brain, near the apex of the pyra-
mid of the petrous bone. The exudation in the right ear must be regarded
as the expression of a reflex neurosis from the trigeminus.

The second case was one of acute otitis media suppurativa, followed by
pyaemia and caries of the mastoid process and endocranial abscess. The
mastoid process was opened by a chisel, and recovery took place in three
weeks, so as to permit the patient to attend dispensary treatment; in one
year, entire recovery, with hearing for watch at nine inches, and for the voice,
across a room.

The third case was one of acute suppurative otitis, with paralysis of the
facial nerve, and marked cerebral depression. There were symptoms of mas-
toid retention of pus. This cavity was opened, and the transverse sinus
accidentally penetrated. The patient, however, seemed to be getting well,
when, on the seventh day of apparent convalescence, she fell back in bed,
and, after becoming cyanotic in the face, died in a few seconds. There was
no post-mortem examination.

vol. 96, no. 1. — jult, 18S8. 7

94 PROGRESS OF MEDICAL SCIENCE.

Alterations in the Labyrinth in Measles.

These alterations pertain to the lymphatics and the bloodvessels. In the
former, the lymph coagulates and the cells accumulate; they also fill up the
semicircular canals and the cochlea. The endothelium undergoes fatty
degeneration. In the bloodvessels, the destruction is nearly complete in the
Haversian canals and in the spiral ligament. Hence the colloid degenera-
tion in the marrow of the bones, and the partial neuroses. The muscles
undergo waxy degeneration. The nerves become gelatinous and, at places,
entirely atrophied. The cells of Corti's membrane are also similarly degener-
ated. Notwithstanding the intensity of these lesions, and the frequency of
auditory complication in measles, permanent deafness is rare as a consequence
of this disease. Reparation seems possible. (Section of Otology. Prof. S.
Moos, Congress at Wiesbaden, September 22, 1887.)

DISEASES OP THE LARYNX AND CONTIGUOUS
STRUCTURES.

UNDER THE CHARGE OF

J. SOLIS-COHEN, M.D.,

OF PHILADELPHIA.

Acute, Infectious, Phlegmonous Pharyngitis.

Senator, of Berlin, calls attention {Miinchener med. Woch., Jan. 17, 1888,
p. 47) under this head to a little known and dangerous fever, perhaps invari-
ably fatal, and mentions two cases subsequently reported in detail (Berli/ter
klin. Woch., Jan. 30, 1888) with extensions.

A metal drawer, aged thirty-six, was admitted September 28th, with tolerably
high fever, disquiet, and slight disturbance of intellect. Two weeks before,
he had been at home for a day or two, then thoroughly well for fourteen days,
when he took cold by drinking ice-cold beer while overheated.

He complained of pain in the throat and want of breath. There was slight
swelling of the throat, especially on the left side, and pain. Great congest ion
in mouth and pharynx. Sensorium became more and more dulled. Fever
slight.

The treatment consisted in cold compresses and fragments of ice. iVath
ensued on the third day, without evidences of suffocation. The urine was
highly albuminous, without morphotie particles, and without blood.

Section revealed suppuration in the peripharyngeal tissues around tin-
large vessels, which reached to the upper part of the thorax ; farther, a very
extensive gastritis and inflammation of the jejunum, a large spleen (splenic
tumor), and parenchymatous nephritis. The patient died without any diag-

Soon after, a second patient was observed in hospital with the same symp-

LARYNGOLOGY. 95

toins, and in whom the diagnosis was made as probable. He was a merchant
who, after a night of dissipation, in which he had eaten ice, was first taken
with the symptoms of acute gastritis and diarrhoea. There soon ensued severe
pain on glutition, hoarseness, attacks of dyspnoea, swelling of the left side of
the neck, with great tenderness, especially of the tonsil. The diarrhoea soon
abated, hut the patient's condition grew more and more serious, and he died
in collapse without suffocation.

The anatomical diagnosis from the autopsy was: Deep phlegmon of the left
side of the pharynx, with extension to the larynx; purulent infiltration of the
left aryepiglottie fold ; decubitus of both vocal bands, with commencing
separation; deep-seated swelling of the gastric mucous membrane, < astritis
prof 1/e ran s ; great hyperplastic and hypersemic splenic tumor; parenchymatous
nephritis: hemorrhagic myelitis. Numerous coagulation necroses in the
kidneys.

Senator recalls two similar cases in his experience, and believes that he has
seen several. There are a few others recorded, but they have always been
regarded as acute oedema of the larynx, or as perilaryngitis. Mackenzie
similarly describes this acute phlegmonous laryngitis, which he has observed
chiefly in nurses, students, and physicians, who are readily septically infected.

There is a series of analogous processes in which tissues, much better
protected than the larynx or the pharynx, are primarily, though rarely,
attacked with an acute suppurative inflammation, without trauma, and with-
out metastasis. There is suppurative acute pleuritis which is soon fatal
under typhoid manifestations, without any evidence being detected of a
primary purulent focus anywhere; the rare cases of purulent peritonitis with-
out origin from the genitalia, or from the bowel ; acute primary osteomyelitis,
perhaps, also, many cases of malignant, ulcerous endocarditis.

Senator believes all these forms in general to be less frequent than the
analogous disease in the pharynx, and chiefly so in consequence of the less
exposed locality of the infection.

We have here a primary pharyngitis. The other changes, extension to the
larynx, splenic tumor, and nephritis, are readily explained. The gastritis only
is peculiar, and it is probable that the gastritis is a result of the constitutional
affection, as it sometimes is in scarlatina. Examination for bacteria has been
without result. The diagnosis is easy. It is an affection associated with slight
fever and disturbance of the sensorium, of which the characteristic points
are pains in the throat and, later, hoarseness, dyspnoea, and dysphagia. It
is distinguished from pharyngeal croup by the simultaneous manifestation of
disturbance of the intellect ; from Ludwig's angina, by the splenic tumor and
the albuminuria. The prognosis, according to Senator's experience, is abso-
lutely unfavorable.

In the discussion on this paper (Deutsche vied. Woch., Jan. 26, 1888), Gutt-
inann regarded the cases related as instances of what is tolerably well known
as erysipelatous inflammation of the pharynx. Virchow mentioned that he
had examined an entire series of such cases, and reported them in 1876-80.
They were infectious processes which affect the pharynx, and thence the
oesophagus, stomach, and intestine, and, in addition, have a strong disposition
to extend from the pharynx and upper part of the oesophagua to the throat and
the parts surrounding the trachea, and from the lower portion of the oesopha-

96 PROGRESS OF MEDICAL SCIENCE.

gus to the mediastinum, and thence to the pleura and the lungs. In many
cases metastasis occurs to other organs. In the latter connection, cases
frequently occur as the result of puerperal diseases. There is another class
of cases which may be designated spontaneous, as there is no special cause
that can be detected.

External Incisions in Retropharyngeal Ab»

Dr. H. BuRCKHARDT, of Stuttgart (Cenlralblatt fur Chirurgie, January 8,
1888, p. 57), urges external incision in preference to direct incision through
the mouth. The advantages claimed are the better examination of the ab-
scess cavity, with the finger if need be. He likewise commends the incision
for extraction of foreign bodies from the retropharyngeal or upper retro-
pharyngeal space before they have produced abscesses.

An incision is made along the inner border of the stemo-mastoid muscle,
through the skin and platysma, at the level of the larynx, exposing the ves-
sels running to the thyroid gland at the level of the thyroid cartilage. These
are pushed outward, and then by keeping close to the larynx, the inner cir-
cumference of the carotid artery can be readily reached in the loose connec-
tive tissue without using the knife. At this level no vessels are given off
from the inner circumference of the carotid. A small opening is now to be
made with the knife, deep down close to the larynx, at the lower level of the
pharynx, into the thickened connective tissue surrounding the abscess, and to
be dilated with a delicate dressing forceps or other similar instrument. Some-
times, a larger or smaller subcutaneous vein communicating with the vessels
of the thyroid gland is found under the platysma, and this should be secured
with two ligatures and be divided, before penetrating into the deep portion of
the wound.

Three cases thus treated successfully are detailed, one in a servant girl
twenty-nine years of age, the second in a servant girl twenty-six years of age
with a splinter of glass in the abscess cavity, and the third in a male infant
seven months of age.

Spontaneous Expulsion of a Laryngeal Polyp,
Dr. B. Fraenkel reports (Deutsche med. Woch., January 12, 1888, p.
case, communicated to him by Dr. Swiderski, of Posen, of spontaneous expul-
sion of a polyp by cough. Hoarseness and dyspnoea began in 1862. A laryn-
geal polyp was detected, and von Bruns wanted to perform laryngofissure. In
1870, a serious hemorrhage occurred, and Swiderski found the larynx markedly
reddened on the left side, and a pear-shaped tumor underneath the left vocal
hand. The hemorrhage ceased after subcutaneous injection of ergotin, but
the dyspnoea remained intense. Patient refused tracheotomy. Despite
topical application of silver nitrate and solutions of ergotin, the danger of
suffocation was not abated. On May 12th, it was so great that tracheotomy
was urgently advised, but it was declined by the patient. On May l'itli,
the patient was found sitting in bed, smoking his segar and taking his coffee.
A aevere paroxysm of cough had expelled the polyp. Microscopically it
turned out to be a fibrous polyp. Despite its shrinkage from long sojourn in
alcohol it was nearly three->|uarters of an ineh long.

LARYNGOLOGY. 97

Fraenkel had never observed the spontaneous expulsion ofalaryngeal polyp,
but had Been a case in which a laryngeal polyp had spontaneously undergone
complete resorption. Such occurrences belong to the greatest rarities.

[A few instances have been noted in the compiler's practice.]

- ; iiyoid Cyst with Displacement of the Larynx.

Drs. Gougi'ENHEIM and Perier report (Annates des Mai. de Voreille et du
fcrynx, Avril, 1888) a case in a female, forty-eight years of age, in which the
larynx was deviated to the left, and its interior altogether inaccessible to
view. Preliminary tracheotomy was performed without anaesthesia, and the
tumor was removed sixteen days later, the patient being discharged well
four weeks after. Laryngoscopic inspection showed complete disappearance
of a tumor from the right side of the larynx, and absolute integrity of the
larynx. The voice had assumed its normal character.

I hi: Action of Caustics on the Nasal Mucous Membrane.

Dr. Bosworth, of New York, contends (Jnurn. Lar. and Rhin., April, 1888)
that the objective point in the treatment of hypertrophied mucous membrane
should not be the destruction of tissue, but rather constriction of the blood-
vessels and diminution of the nutrition, which would counteract the hyper-
trophy. He prefers chromic acid over all other agents for this purpose.

Acute Tonsillitis.

Griffiths (Brit. Med. Journ., April 28) reports great success in relieving
intense pain and facilitating glutition and articulation, by pencillings with a
four per cent, solution of cocaine. They were repeated every two hours for
five days, with permanent benefit.

A \ Unusual Case of Laryngeal Papilloma.

Vox Zii;ms-kx has reported (Miinchener med. Woch., March 8) a case of
papilloma of the larynx, of apparently five years' duration, in a male patient,
fifty-seven years of age. Repeated intralaryngeal procedures, during a period
of three years, having been followed by temporary improvements only, trache-
otomy became necessary on account of intense stenosis from extensive papil-
lomatous excrescences beneath and above both vocal bands. The patient
died from heart failure as he was recovering from the narcosis immediately
after the operation.

vtion the growth had the macroscopic appearance of carcinoma, but
microscopic examination showed that, instead of a carcinoma, it was a papil-
loma with cell-nests in the superficial portion of the mucous membrane. The
■logical details are given by Bollinger, who describes the growth as an
epithelial tumor of papillary form, which, in a few points only, showed char-
acteristics which indicated a certain malignancy. The cause of the sudden
or gradual change, as may have been, of a benign growth of long standing
into a malign one, was attributed to a certain depression in physiological
resistance, from great age, intemperance, cardiac debility, and insufficient

98 PROGRESS OF MEDICAL SCIENCE.

nutrition, as well as to topical irritation from mechanical lesion and operative
procedure. While believing this case to be an evidence of the transformation
process between the benign and a malign neoplasm, Bollinger refers to the
opinion of Virchow that the so-called cancer-nests may appear in benign
epithelioma, although less frequently, and in more regular arrangement than
in carcinomatous growths.

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

OF PHILADELPHIA.

Puerperal Mastitis.

Olshausen, in the Deutsche medicinisehe Wochenschrift of April 5, 1888,
contributes an article on this subject, which appears also in the most recent
edition of Schroder's work.

The etiology of mastitis has become evident through bacteriological
researches. The staphylococcus is the germ most frequently the infective
agent, and the path of invasion is, in the greater number of cases, the milk
ducts ; by these avenues the various lobes and lobules are infected. Escherich
and Bumm have found bacteria in the milk from lobes not yet inflamed.
Bacteria also gain access readily to the breast through fissures in the nipples.

Mastitis occurring through infection of the milk ducts becomes parenchy-
matous; while that following fissured nipples u phlegmonous, whose causative
germ is the streptococcus pyogenes. Decomposition of milk may be effected
by bacteria, and the alkaline reaction be changed. Phlegmonous mastitis is
characterized by diffuse inflammation of the subcutaneous tissue and extru-
sive redness of the skin ; secondarily purulent inflammation of lobules may
occur.

The retention and accumulation of milk in the breast cannot cause mastitis;
but the products of the decomposition of milk, lactic and butyric acids, with
the formation of casein, favor the development and extension of bacteria.

In cases which do not go on to suppuration, mastitis is generally eared in
two days. If fever persists for two days, suppuration has occurred ; in from
six to ten days, with a persistence of pain and redness, deep-seated fluctuation,
and the accumulation of a large quantity of pus are found. Extensive bur-
rowing of pus and acute pyaemia may develop. Suppuration and burrowing
may persist for months, and greatly reduce the patient.

Mastitis occurs most frequently in primipans, t»7.t! per cent. (Winckel).
Among 972 patients at Halle during four years time, 81 cases of mastitis
occurred, with suppuration six times.

The prophylactic treatment consists in cleansing the nipple, disinfecting all
fissure- about the nipple, and cleansing the child's mouth. The removal of

OBSTETRICS. 99

the child from the breast is imperative so soon as mastitis develops. In the
burger number of cases, if the child be taken from the breast in the first
twenty-four hours after the initial chill, the mastitis will resolve without sup-
puration; bandaging and a laxative are also proper. Suppuration must be
treated surgically, by incisions radiating from the nipple.

A subareolar mastitis, or circumscribed phlegmon, may occur without general
infection of the gland. Occasionally, submammary abscess forms beneath the
gland, which may lead to prolonged and dangerous infection.

Cjssarean Section at the St. Petersburg Maternity.

Krassowski reports, in the Archiv fur Gynakologie, Band 32, Heft 2, five
Porro and two Sanger operations, with a maternal mortality of one, and a
foetal mortality of two. The indications for operation were rupture of the
uterus, tumor of the pelvis, cancer of the uterus, and contracted pelvi.-.

Interesting points in his technique are the use of thymol, 1 to 1000, for in-
struments, as carbolic acid is thought to dull cutting instruments, and bin-
iodide of mercury, 1 to 4000, for other purposes of antisepsis. Silk was
used for sutures and ligatures. The wound was hermetically sealed with
collodion containing biniodide of mercury.

The Relative Frequency and Causes of Fostal Positions.

haublin contributes a statistical paper to the Archiv fur Gynakologie,
Band 32, Heft 2, in which he concludes that gravitation causes occipital pre-
sentation ; that lax abdominal walls permit the child's back to turn to the
mother's right side in multipara? more often than in primiparae; that in con-
tracted pelves the uterus shapes itself to accommodate the foetus, and that the
I back is on the mother's left side in the proportion of 1.7 to 1 of posi-
tions on her right.
The most constant cause of anomalous positions is contracted pelvis.

Pregnancy with Gangrenous Ovarian Cyst and Peritonitis;
Ovariotomy; Recovery.

Sippel describes in the Centralblatt fur Gynakologie, No. 14, 1888, a case
of pregnancy at seven months, with ovarian cyst which became gangrenous
through a twisted pedicle. Peritonitis and premature birth followed. Ovari-
otomy was successfully done two days afterward.

Sippel noticed that, in spite of ovarian disease, uterine involution had pro-
ceeded more perfectly than usually.

A Fatal Case of Early Tubal Pregnancy.

The view that tubal pregnancy should be operated upon as soon as diag-
nosticated, was strikingly illustrated by a case reported by Zucker (Central-
blatt fiir Gyna tfo. 15, 1888). Two or three weeks after conception
the patient had two attacks of abdominal pain, the first of which was relieved
by a laxative; the second resulted in summoning Zucker.

He found the patient suffering from shock; an ill-defined, plastic mass lay

100 PROGRESS OF MEDICAL SCIENCE.

in the left parametrium, and was very sensitive. Opium and cold compresses
were ordered; as the condition of collapse deepened the patient was taken
to Veit's clinic (Berlin), where laparotomy was performed by Veit ten hours
after the patient was first seen.

A gallon of blood was found in the abdomen, and right tubal pregnancy
with rupture. Owing to the patient's collapsed condition, the operation was
rapidly done (in ten minutes); the tube was ligated and removed, and trans-
fusion and stimulation practised, but unsuccessfully. Death occurred from
hemorrhage.

Before the operation, and with the patient narcotized, no tumor could be
distinctly outlined, and Zucker calls attention to the impossibility of recog-
nizing a tumor early.

Veit has operated ten times, on seven patients before hemorrhage had oc-
curred, all of whom recovered. Of three operated on after hemorrhage had
occurred, but one recovered.

Involution of the Muscular Tissue of the Puerperal Uterus.

Sanger [Beitrage zur rathol Anatomie, 1887, S. 134) has examined the
muscular tissue of 17 uteri, from four hours to fifty-five days after delivery.
He found that the muscle fibres diminished in length and breadth, and that
the process is not a fatty degeneration, but normal metabolism ; fatty changes
are pathological.

Subinvolution is not a disease, but a condition caused by faulty proet -
in the general organism. Wounds of the puerperal uterus, as in Csesarean
section, heal promptly.

The Lower Uterine Segment.

Blanc (Nouvelles Archives d' Obstetrique et de Qynecologie, No. 1, 1888) con-
cludes a clinical study of the subject as follows: Dilatation of the cervix
goes on during the five days before labor ; it gradually blends with the uterine
segment. The cervix remains closed until labor less often among primiparae.
The lower uterine segment extends from the contraction ring to the internal
os: just before labor, the cervix enlarges, forming a secondary inferior seg-
ment separated from the primary by the adherence of the fatal membranes.

Puerperal Septicemia from Atmospheric Infection.

I'nderhill reports a case of septicaemia caused by the patient's proximity
to a patient with gastric cancer. The membranes were adherent, and were
removed by the hand within the uterus. The next day, an intrauterine injec-
tion of 1 to 5000 bichloride of mercury was given. The case was fatal.
Also, a case of abortion at three months in a woman who had assiduously
DQned a pymnic relative. Septica'inia proved fatal in spite of antiseptic
treatment. Two cases of mild septicaemia from sewer gas are added.

In the first, attention is naturally directed to the artificial delivery of

adherent membranes as th -casion of sepsis. — Ed.] — Edinburgh MediocU

Journal, .May. |

LARYNGOLOGY. 1<>1

The Electrical Treatmkm <>f Extrauterine Pregnav

Broth ii:- {American Journal of Obstetrics, May, 1888) reports a case of
tubal pregnancy treated by eight applications of a strong faradic current, for
fifteen minutes each, during two weeks. Cessation of symptoms; disappear-
ance of the tumor; and, later, normal pregnancy and parturition followed.

bulates forty-three cases treated by electricity, most of them by faradic
or galvanic currents, with two deaths. The foetus was destroyed in all but two
cases : in several, the fetus was displaced from the tube into the uterus. In
more than half, the tumor disappeared. In two cases, suppuration in the sac
followed, with spontaneous evacuation and recovery.

Electrical treatment is indicated up to four months' pregnancy.

Parturition amoxo the Poor.

JOHHSTOB', in the American Journal of Obstetrics for May, 1888, reports the
results of his study of 318 women at the Washington Dispensary, as follows:

Sterility is not infrequent, and dependent on anaemia. Ovarian and tubal
disease, with pelvic peritonitis and cellulitis, are not common. Abortion is
frequent, and results from violence. Labor is generally easy and uncom-
plicated. Convalescence is usually retarded by debility and work, occasion-
ally it is very rapid.

Lactation frequently fails from maternal debility. Lesions and diseases
caused by parturition are rarer and milder than in well-to-do women.

Accidents with Bichloride of Mercury.

::, in treating a case of retained placenta after manual delivery, gave
intrauterine injections of bichloride of mercury, 1 to 2000, using two catheters ;
well-marked intoxication with mercury followed, from which the patient
made a tedious recovery.

■ ard disinfected the uterus with bichloride solution, 1 to 3000, after
abortion at six weeks. Intoxication followed, from which the patient recov-
ered. Both patients were anaemic. — Nouvelles Archives <T Obstetrique, No. 4,
1888.

Hydatid Cysts of the Uteri -

■ and Secheyron {Archives de Tocologie, No. 12, 1887) find that
hydatid- may penetrate the uterine wall, grow and rupture. They may
furnish an effectual obstacle to labor, and cause uterine displacements by
their weight.

Diagnosis would be based on symptoms of a tumor, and the discharge of
hooklets. Treatment should be evacuation ; if needed, the cervix may be
split, and haemostatic forceps employed.

The Causes of I1yi>i;amnios.

Mantel concludes, from an elaborate study of hydramnios {Archives de
Ibcolo.' \ i. 1. 2, .!. and 4. 18$*>, that hydramnios is acute and chronic.

102 PROGRESS OF MEDICAL SCIENCE.

The attachment of the placenta in the lower segment of the uterus, and
pressure upon the placenta and cord resulting from this location, impede
placental circulation, and result in accumulation of fluid in the amniotic
cavity; this he considers acut° hydramnios.

Chronic hydramnios is generally caused by syphilis or foetal monstrosities.

The Treatment of Pregnancy Complicated by Ovarian Cyst.

Terrillon (Archives de Tocologie, April, 1888) concludes that in these cases
ovariotomy, and not puncture of the cyst, should be performed. Ovariotomy
gives the best results at three, four, or five months pregnancy; after the fifth
month it is best to wait until after labor before operating. The uterus should
be avoided during the operation ; if wounded, it should be emptied and sutured.
The technique is that ordinarily employed.

Birth Palsies.

Gowers, in a clinical lecture {Lancet, April 14 and 21, 1888), divides birth
palsies into peripheral and cerebral. The former are usually of the facial
nerve, and those of the arms ; they are rarely severe, and recover sponta-
neously.

Cerebral palsies occur most frequently after first and difficult labors. Extrava-
sation of blood over the cortex, or at the base of the brain, is the usual con-
dition, resulting in death or tedious recovery.

In diagnosis, symptoms of severe injury or defective development of the
nervous system are present, without history of definite onset. Chronic spinal
disease is rare in children. In birth palsies, reflexes are excessive ; in muscular
diseases, they are not increased.

Prognosis : tendency to slow improvement. Treatment by drugs, by electri-
city and tenotomy is useless. Rhythmical gymnastic training, with hygiene,
is of value.

Rupturkd Tubal Pregnancy Occurring Twice in the Same Patient.

Tait (British Medical Journal, May 12, 1888) reports the case of a patient
who had a ruptured tubal pregnancy of the right tube, cured by operation
three years previous to writing. Normal pregnancy and parturition after-
ward occurred.

She then became pregnant, and at four months died of hemorrhage from
ruptured tubal pregnancy of the left tube (verified by post-mortem examina-
tion).

Tait remarks that the patient, although she had passed through a similar
accident, had no knowledge >f her condition until rupture occurred. He has
never been calleil to a case before rupture but once; on that occasion, positive
diagnosis was not made until rupture and operation.

In the case reported, the ovum was in the left cornua of the uterus, and
physical examination could not have diagnosed the abnormality before rupture.

Hysterectomy was Indicated, l>ut aid was summoned too late.

G Y.VECOLOGY. 103

GYNECOLOGY.

UXDER THE CHARGE OF

SENBY C. COE, M.D., M.R.C.S.,

or JflW YORK.

Recto- vaginal Furti

( "h !:■ >b.\ k Wiener med. Blatter, 1887, Nos. 27-33) infers from the statistics
of the Vienna Hospital that recto-vaginal tistulae are more difficult to cure
than vesico-vaginal. Out of twenty-four private patients with the former
lesion, nine were operated upon, six being cured after nine operations. Among
the common causes he notes the use of Zwanck's pessary, of which he strongly
disapprove*. One fistula that resulted from wearing this instrument was
three and one-half inches in circumference.

Incontinence depends upon the shape of the opening and the amount of
cicatricial contraction. Incontinence of gas may be present when there is no
fistula, from traction on the sphincter by a perineal or vaginal cicatrix, and
can be relieved by excision of the cicatrix. The position of the fistula is of
importance; if located in the posterior fornix, or communicating with the
small intestine, complete incontinence is the rule, although temporary closure
may be effected by hardened feces. An opening in the thin portion of the
recto- vaginal septum, if recent, may be healed by applying caustics, the rectal
side of the opening having first been closed by inserting a cotton tampon
into the rectum. This treatment, to be successful, must be practised early.
During the last two years, the writer has operated entirely under cocaine
anaesthesia, injecting a five per cent, solution. His conclusions are : 1. The
fistula should never be closed from the rectal side ; 2. If it is confined to the
recto- vaginal septum, if there is no cicatricial tissue in the rectum, and the
sphincter is intact, the fistula should be closed directly from the vaginal side,
providing the vagina is sufficiently capacious to allow proper room for work ;
3. If the opening is low down, if there is much traction on its edges upon the
tl side, if the sphincter is wanting or incompetent, or if the vagina is
narrow to allow convenient manipulation, the septum should be split,
and the case treated as one of ordinary laceration through the sphincter.

Peritoneal Drainage by Means of Iodoform-wick.

PlSKAgKK, assistant to Professor Breisky, of Vienna, reports (in the Medi-
■>he Jahrbueher der k. k. GeselUchaft der Aerzte, 1888) a number of cases of
laparotomy and vaginal hysterectomy in which this method of drainage was
employed with excellent results. Drainage of the peritoneal cavity is indi-
1, he believes, under these circumstances: 1. In cases of extrauterine
. nancy where the sac cannot be entirely removed ; 2. When after the
enucleation of an intra-ligamentous cyst a large cavity is left ; 3. In incom-
plete ovariotomy, t. e., where a portion of the sac is left behind ; 4. When

104 PROGRESS OF MEDICAL SCIENCE.

numerous adhesions have been separated ; 5. When pus or septic fluid has
escaped into the cavity during the operation.

After reviewing the various methods of drainage, he notes the following
advantages possessed by tampons of lamp-wick: The secretion is promptly
removed, being more thoroughly absorbed than by iodoform-gauze, the capil-
lary action with which is three times less than with the wick. The latter
may be packed into all the recesses of the wound, so as to drain them
thoroughly, which result is not attained with a stiff tube; moreover, when
filled with iodoform, it can be safely left in situ for a considerable period, thus
avoiding that disturbance of the wound and patient which is unavoidable
where a tube must be constantly emptied. The patient can assume any posi-
tion without fear of interfering with the drainage, and the entrance of air
into the cavity is less to be feared.

To the objection urged against the wick, that it becomes engaged in the
granulations within the sac, and that it is consequently difficult and danger-
ous to remove it, the writer replies that this is less likely to occur than when
iodoform-gauze is used, and may be avoided by the exercise of proper care
and gentleness. As soon as the material is saturated it should be removed,
which is readily accomplished within forty eight hours after the operation.
If removed at a later period, it should be pulled out very slowly, the inner
strands being first detached, then those at the periphery. In cases of vaginal
extirpation of the uterus, Breisky sometimes leaves the wick in position for
two weeks (!), and has never observed any intestinal or peritoneal adhesion in
consequence of its prolonged contact with the parts.

The material is prepared by boiling wick in a solution of bichloride (1 to
1000), or carbolic acid (five per cent.), and then immersing it in a mixture
consisting of five parts of iodoform, ten of glycerine, and seventy of alcohol.
Or the wick, after being boiled, may be dipped in a ten per cent, solution of
iodoform in ether. After soaking for twelve hours in either of the latter
fluids, the wick is wound in balls and is kept in a glass jar.

The Treatment of VB9IOO-VAOIFAL Fistula.

Herff (Frauenarzl, 1888, Heft 1) recommends the closure of the fistula by
splitting the vesico-vaginal septum around the opening, doubling in the
nndenuded edges of the vesical ami vaginal mucosa respectively, and uniting
each by deep and superficial sutures. The advantages claimed for this
method are:

1. It will be necessary to remove only such tissue as is actually cicatricial.

2. Large raw surfaces are brought in apposition, thus insuring reunion.
8. The opposite edges of mucous membrane fall together naturally.

1 When there is so much cicatricial tissue in the vagina that it is impos-
sible entirely to excise it, by splitting the septum and uniting the under sur-
face of one edge of the fistula to that of the other, the operator avoids the
Mity of opposing two cicatricial edges.

5. As the resulting cicatrix is parallel to the urethra, there is not danger of
Contraction of the hitter canal.

I'-. Since there is no loss of tissue, it is always possible in case of failure to
operate subsequently by the usual method.

GYNECOLOGY. 105

[By reference to the DuUin Journal of Medical Sciences for May. 1861, the
reader will observe that the above description corresponds closely with tbat of
the operation originally devised by Collis, to whom Tait (in the same journal
foe May, 1888) handsomely acknowledges his indebtedness.— Ed.]

The Operative Treatment of Dilatation and Relaxation of the

Urethra.

i.\<.-n:<>M [Berliner Mm. Wochenschrift, 1887, No. 40) reports cases of in-
continence of urine, due to extreme relaxation of the urethra, in the treatment
of which he practised a modification of Frank's operation. Instead of re-
moving a wedge of tissue including the entire thickness of the urethro- vagi rial
septum, he left the urethral mucosa intact, aiming to obtain contraction of
the urethra by the subsequent granulation. In one case, primary union oc-
curred, in the other by granulation. The result in both instances was quite
satisfactory.

Successful Case of Ovariotomy on the Second Day after Delivery.

Sippel (Centralblatt fur Gyniikologie, April 7, 1888) operated upon a patient
who had reached the seventh month of pregnancy with a large ovarian cyst.
She was attacked with severe general pains in the abdomen, with tympanites,
the temperature rising to 101.5°. At the same time, there was increased
tension in the cyst. From the fact that the tenderness (originally confined
to the region of the tumor) became general, and the sudden development of
pain and fever, a diagnosis of torsion of the pedicle was made, and immediate
interference was regarded as justifiable.

She was admitted to the hospital for the purpose of having laparotomy
performed, and was delivered spontaneously the same night of a living child,
the placenta following soon and the uterus contracting well without hemor-
rhage. It was decided to pospone the operation until involution had pro-
ceeded to some degree, in the hope that the circulation in the pedicle might
be naturally reduced, but the symptoms continued to be so urgent that delay
would have been fatal. Accordingly, on the morning of the second day after
her delivery, the patient's abdomen was opened, the incision being extended
above the umbilicus, on account of the size of the tumor. The peritoneum
was thickened and congested, the intestines were deeply injected and covered
with organized lymph, although not adherent, and the tumor presented a
blackish appearance. The short, thick pedicle was twisted once about its
axis, so that the circulation in its vessels was entirely arrested and gangrene
was imminent. The patient made a rapid recovery ; the temperature on the
evening following the operation rose to 101.1°, then gradually fell to normal.
She left her bed at the end of the second week, and was discharged on the
twenty-first day, the uterus having actually undergone more rapid involution
than after a normal labor.

Cavernous Degeneration of the Ovaries.

Under this term, Gottschalk (Archiv fur G\inab>b,gie, Bd. xxxii. Heft 2)
•describes the condition of the ovaries in a case of which the following is a

106 PROGRESS OF MEDICAL SCIENCE.

brief history: A woman, set. twenty-eight, who had been sterile for ten
years, began to suffer from menorrhagia a year after marriage. Metror-
rhagia followed and became profuse. It was several times relieved by curet-
ting, but again recurred, so as to result in profound anaemia. No cause for the
hemorrhages could be discovered. Finally, as a last resort, the uterus and
ovaries were removed per vaginam, a complete cure following the operation.

The uterus was of normal size, the mucosa was not hypertrophied, and to
the naked eye the organ presented no morbid changes. The ovaries were
enlarged and deeply congested, as was shown on section. On microscopical
examination they presented a general angiomatous structure, while the vessels
of the uterine mucosa were dilated.

The writer believes that the hemorrhage would have been relieved by the
removal of the appendages alone, although, since the cause was so obscure,
extirpation of the uterus was justifiable under the circumstances. Theo-
retically, it seemed as if the congestion of the uterus might be relieved by
ligating the anastomoses between the ovarian and uterine arteries, an opera-
tion which might be performed through the vagina (!), although the result
would hardly be permanent; but as the ovaries were so thoroughly diseased,
oophorectomy was preferable.

It was clearly impossible to recognize cavernous degeneration of the ovaries
before operation, since they were simply felt to be somewhat enlarged; how-
ever, this condition might be suspected in a case of persistent uterine hemor-
rhage, in which the organ was of normal size, and the curette brought away no
hypertrophied tissue, while a careful examination of the pelvis failed to disclose
any other cause for the symptom. It should not be forgotten that menorrhagia
is a symptom of oophoritis, but the hemorrhages are less profuse than those
which attend telangiectasis of the ovaries, and in the latter condition the
ovaries themselves, though enlarged, are not the seat of pain.

Ascites as a Symptom of Torsion of the Pedicle in Cases of Ovariax

Cyst.

Schtjrinoff (Centralblatt fur Gt/nak., April 14, 1888) reports the following
case, which, so far as he could ascertain, is unique: A peasant woman, set.
twenty-seven, had had an ovarian cyst for ten months. She was formerly in
the hospital for three weeks, but declined an operation. A week before she
entered the second time, ascites began to develop, and increased rapidly, so
that it was necessary eventually to tap her and withdraw three gallons of
fluid. Four days later, it had reaccumulated, and was again withdrawn ;
three days after, laparotomy was performed. A large adherent colloid cyst
was found, growing from the left side, the pedicle being twisted half round
its long axis. This exactly confirmed the diagnosis which was made before
opening the abdomen; all other causes having been excluded, it had been
decided that the ascites was due to torsion of the pedicle.

Commenting on the case, the writer thinks that the torsion must have
occurred at the time when the ascites was first noted. The separate loculi of
the cyst showed evidences of partial obstruction to the circulation, in the form
of hemorrhages, there being, however, no signs of gangrene. The peritonize
adhesions were recent. He was unable to find any report of a similar case.

GYNECOLOGY. 107

[The writer's explanation of the sudden development of ascites is by no means
satisfactory. The obstruction to the circulation in the pedicle resulting from
partial twisting, could hardly produce such a result, unless the vessels were
of enormous size ; neither would this be occasioned by a similar obstruction of
th"se in the adhesions. If it was directly due to the accident, it must be
attributed to pressure on the large systemic veins, consequent to the change
in the position of the cyst. — Ed.]

The Condition of the Corporeal Endometrium in Carcinoma of the

kvix Uteri.

Abel (Archivfur Gynilkologie, Bd. xxxii. Heft. 2), has made a special study
of the microscopical appearances of the uterine mucosa in cases of malignant
disease limited to the cervix, in order to determine its practical bearing upon
the question of vaginal extirpation. The general opinion is that in the early
stages of epithelioma of the cervix neither the cervical nor the corporeal
endometrium is diseased; in short, the carcinoma is confined to the cervix
until the parenchyma near the os internum has become involved.

Abel's observations have led him to a directly contrary conclusion. In
seven uteri, removed per vaginam for epithelioma of the cervix, the corporeal
endometrium was the seat of advanced changes, while the cervical was only
moderately diseased. In three cases there was sarcomatous degeneration,
while in the others there was present a chronic hyperplasia of the mucosa,
affecting both the glands and the interglandular tissue. In every instance
the microscopical appearances were strongly suggestive of round and spindle-
celled sarcoma, although it could hardly be possible that a mixed growth
existed (such as was described by V-irchow), because the carcinomatous and
quasi-sarcomatous tissues were separated by a healthy zone. It might be
explained by supposing that the same cause gave rise to different morbid
effects in the mucosa lining the cervix and body of the uterus.

In conclusion, the writer infers that, on anatomical as well as on clinical
grounds, total extirpation of the uterus is justifiable in every case of epithe-
lioma of the cervix.

Observations on Pyosalpinx.

GU8SEROW {Ibid.) reports thirty-one cases of pyosalpinx in which lapa-
rotomy was performed, with one death. The symptoms are principally due,
he believes, to the accompanying disease of the ovaries, which is rarely
absent. The poorer class of patients, who are unable to rest, are most liable
to attacks of perimetritis, which aggravate the original trouble, as shown by
the presence of dysmeuorrhcea. He has never observed any symptoms which
he regarded as peculiar to pyosalpinx. Menorrhagia is due more often to
obstruction to the pelvic circulation by old perimetritis. The danger from
rupture of the tube and escape of pus into the cavity has been exaggerated.
Gusserow ha>* introduced such pus into the peritoneal cavity of a rabbit
without bad results, but this proof is negative, as there may be a peculiar
septic quality in some specimens of purulent matter, which is absent in
others. Infection may be communicated to the contents of a pyosalpinx
(previously innocuous) from a wound in the lower genital tract, resulting in

108 PROGRESS OF MEDICAL SCIENCE.

ulceration of the tube and fatal peritonitis. This accident, as well as rupture
of the tube by manipulation, is less common than formerly, since we have
learned to recognize the existence of pyosalpinx.

Removal of the diseased tube and ovary offers the only prospect of a radical
cure. Gusserow makes as small an incision as possible, and never allows the
intestines to escape. If the adhesions around the tumor cannot be broken up,
aid may be afforded by pressure through the vagina, made by the finger of an
assistant, or by a colpeurynter. Both ovaries should be removed, even in
cases in which the disease is strictly unilateral.

In a considerable number of cases the operation is followed by para- or
perimetritis, which renders it a failure, so far as regards the relief of pain ;
indeed, the pain may be more severe than before. Still, there is always a
chance that the exudations may be absorbed, and the patient is, at least, free
from the danger of rupture of the tubes, as well as from the liability to
recurrent attacks of pelvic inflammation.

Laparotomy for Myoma of the Uterus.

Professor Albert ( Wiener med. Presse, April 15 and 22, 1888) reports in
detail twenty cases of myomotomy with one death. His method of opera-
tion is briefly as follows : The uterus is lifted out of the cavity, and the
cervix is surrounded with a rubber cord. If the bladder is drawn upward
over the anterior surface of the tumor, it is not dissected off before the liga-
ture is applied, but a pin is passed through the superficial layers of the uterine
wall just above the bladder, and then the cord is made to encircle the tumor
above the pin. If the tumor dips downward into Douglas's pouch, another
pin is inserted in the same manner, thus avoiding the danger of applying the
constriction at too low a level. The muscular tissue over the tumor is now
incised, and the growth is rapidly enucleated by means of the finger, scissors,
or elevator. The parietal peritoneum is united to that covering the uterus
at a distance of about two-fifths of an inch below the ligature; if there is
too much tension, it may be relieved by slipping the tube upward a little, or
applying another just above it.

The needle first inserted serves to suspend the stump, which is formed by
trimming off the mass above the ligature in the usual manner, and is treated
according to the extra-peritoneal method. In no instance did necrosis of
the stump attributable to the use of the rubber ligature occur; in fact, it ifl
more likely to take place, the operator thinks, when the stump is sutured and
dropped back into the cavity.

Mote to Contributors. — All communications intended for insertion in the Original
Department of thi< Journal are only received with the distinct understanding that they
»re sent to this Journal alone. Gentlemen favoring us with their communications are
considered to be bound in honor to a strict observance of this understanding.

Liberal compensation is made for articles used. Extra copies, in pamphlet form, will,
if desired, bt famished to author* in lieu of compensation, provided the request for them
be written on the mami.irripf.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

AUGUST, 1888.

CONTRIBUTION TO THE DIAGNOSIS AND SURGICAL TREAT-
M KNT OF TUMORS OF THE CEREBRUM.

By R. F. Weir, M.D.,

SURGEON TO THE HEW TORE HOSPITAL J PROFESSOR 07 CLINICAL 8URGERT IX THE COLLEGE 0E PHYSICIAXS
AXD SURGEON'S, SEW TORK ;

AND

E. C. Segcin, M.D.,

MEMBER Or THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC.
II

[arks upon the diagnosis which should be preliminary to
the Surgical Treatment of Cerebral Tumors. [By Dr. Seguin.]

The surgeon's attempt to remove a cerebral tumor, and thereby pro-
long, or even in some cases save life, must necessarily be based upon an
accurate diagnosis of the lesion. The modes of examination and methods
of reasoning necessary to attain such a diagnosis being so unlike the
methods of diagnosis employed by surgeons, and requiring so much
special experience in neurology, the services of both a physician and a
surgeon are required. The medical examination is the necessary pre-
liminary to an operation, and a neurologist can hardly possess the surgical
skill and experience which are required, not simply to remove the tumor,
but to insure a reasonably certain aseptic condition of the wound and
render the operation of trephining in itself not specially dangerous.

The medical diagnosis of a case of supposed tumor of the brain should,
before an operation is attempted, be carefully worked out in not less
than five lines of inquiry, or secondary diagnoses. 1. The diagnosis of
tumor within the skull, and more especially in or upon the cerebral

tol. 96, ho. 2.— ArGCST, 1888.

110 WEIR, SEGUIN, CEREBRAL SURGERY.

hemispheres. 2. The diagnosis of the exact location of the tumor. 3.
The diagnosis of the depth of the tumor ; whether it be cortical or sub-
cortical. 4. The diagnosis of the solitude or multiplicity of the tumor.
5. The diagnosis of its nature.

First. The Diagnosis of Tumor of the Cerebrum.

As a rule, this is accurately made by the experienced physician. The
gradual development of symptoms, such as headache, convulsions local
or general, paresis, and paralysis, co-extension of these symptoms,
moderate anaesthesia, choked disk, hemianopsia, stupor, coma, slow pulse,
leave hardly any room for doubt. The grouping of symptoms is most
various, and largely depends upon the location of the growth, upon its
size, and upon personal tendencies of the patient. Anaesthesia is rarely
great, headache may be entirely absent, and, in my experience at least,
choked disk is not the rule in strictly cerebral tumors. We must, of
course, make allowance for exceptional cases, such as those which pre-
sent only choked disk and an occasional general convulsion, those in
which an apoplectic attack is the first symptom that seriously attracts
attention, etc. I think that I shall not overstate the case in saying that
while the most experienced and careful observer may find at an autopsy
a tumor which had caused no symptoms, yet when the symptoms of
tumor are present, almost every practitioner should be able to make the
diagnosis.

Second. The Diagnosis of the Topographical Location
of the Tumor.

This diagnosis is arrived at by an application of our empirically
acquired knowledge due to the clinical and post-mortem studies of
Broca, Hughlings Jackson, Charcot, Wernicke, Nothnagel, Exner,
Luciani, and many other observers (several of them our own country-
men), and of physiological laws of cerebral action, as elucidated by the
researches of Hitzig, Ferrier, Munk, Putnam, Franck, Horsley, and
others. To discuss the subject thoroughly is impossible in a paper like
this, and I must ask to be allowed to state the bases of a solid localiza-
tion diagnosis in a summary way.

1. There are parts of the cerebrum which are in a certain sense inex-
citable, and lesions of which produce no special or localizing symptoms.
When tumors are located in these areas of the brain, the patient exhibits
only general symptoms of cerebral disease, such as headache, diffused or
localized, general convulsions ; pressure symptoms, such as reluctant full
pulse, perhaps slow pulse, choked disk, blindness, stupor, with or without
partial hemiplegia and hemiansesthesia, dysarthria, dysphagia, coma,
with hyperpyrexia, and Cheyne-Stokes respiration at the end. The
parts of the cerebrum which belong to this category are (a) the fronta

WEIR, SEQUIN, CEREBRAL SURGERY. Ill

lobes strictly speaking, except the caudal extremities of its external
gyri, more especially the second and third ; (b) the apex and base of the
temporal lobes on both sides, and the whole of the lobe on the right
side ; (c) the external and basal aspect of the occipital lobes ; (d) parts
of the parietal lobes ; and (<?) the central ganglia. The fasciculi of
medullary substance connecting those parts with the base of the brain,
and with other parts of the cerebrum (commissural fibres) are included
as inexcitable parts. Progress in pathological and experimental knowl-
edge will, doubtless, reduce these inexcitable areas, but I think that I
have stated them as a conservative view of cerebral physiology now
dictates.

2. We have left two irregular divisions of the cerebrum, lesions of
which give rise to special, definite, localizing symptoms ; these are, first,
the excitable or motor zone, cortex and attached fasciculi ; and second,
the known sensory zones, with their fasciculi. The fasciculi from all
these zones converge, and are crowded together at the knee and caudal
portion of the internal capsule, as it passes ventrad between the basal
ganglia, and leaves the cerebrum.

The motor zone comprises in its cortical aspect the following convolu-
tions on both sides of the brain : the caudal extremities of the third,
second, perhaps of the first frontal ; the pre- and postcentral gyri, and
their prolongation within the longitudinal fissure, known as the para-
central lobule. These gyri and portions of gyri are all placed dorsad
of the fissure of Sylvius, and are grouped about the fissure of Rolando.
That the folds of the insula (island of Reil) have motor properties, is
probable. These parts all receive their supply of arterial blood through
one channel, viz., the middle cerebral artery ; and all of them (with the
exception of the insula) can be accurately mapped out on the head by
means of, one or another of the several methods of cranio-cerebral topog-
raphy. The subjoined diagrams illustrate the determination of the
position of the motor zone by Broca's method.

The motor zone, as its name implies, has motor functions, and has an
anatomical and physiological connection with the muscular apparatus
of the opposite side of the body, as follows : The base of the third
frontal gyrus (left side) with the delicate movement of speech ; it
also, and the adjacent base of the precentral gyrus with the lingual
muscles, the base of the second frontal gyrus at its confluence with the
precentral, with the muscles of the face ; the middle third of the pre-
central gyrus with the muscles of the forearm and hand ; the upper third
of the pre- and postcentral gyri with the muscles of the arm and shoulder;
the ends of the pre- and postcentral gyri (paracentral lobule) with th«
muscles of the foot, leg, and thigh. Probably the muscles of the hip
and abdomen are innervated from the bend of the above-named gyri as
they dip down into the longitudinal fissure. Those portions of the motor

112

WEIR, SEGUIN, CEREBRAL SURGERY.

zone, whose limits are probably not definite, are designated as " motor
centres." Thus we have, from below upward, the centres for speech, for
lingual, manual, brachial, scapular, abdominal, femoral, crural and

Fig. 7.
Uregma-

I somM

lift. Sand 7.— Simplified cranial and cerebral Align mi, with Brooft'l line*. For detailed explana-
tion of theee diagram* tee Popper's Sj/tlom of Utiltkf, vol. v. pp. iU-ttO, and Orow's Sarjerf, vol. ii. p
I KIr. A thejoreacentii- mark in >li<-ataa Dr. Welr'a llr-l ttvphlno opening.

pedal movements. A rent re for ocular movements doubtleaa exists, but
it has not yet been determined ; it is .pute eertainly not in the second
frontal gvru«. as claimed by Furrier and Horsley. Another question-

WEIR, SKGUIK, CEREBRAL SURGERY. 113

able motor centre is that for laryngeal movements, which is being sought
for in the caudal extremity of the right third frontal (homologous with
the speech centre on the left side, in right-handed persons). The entire
motor zone is easily reached by trephining, the only obstacles in the way
being the middle meningeal artery, and, in operations near the vertex,
the superior longitudinal sinus.

Of the sensory zone we have as yet positive knowledge of only two of
its centres or areas, a probable knowledge of a third, and a suspicion of
a fourth. On the left side of the cerebrum the first or dorsal temporal
gyrus appears to be the organ for vocal or linguistic audition (a u d on
7). Upon the inner, mesial aspect of each occipital lobe is a trian-
gular gyrus which has a wonderful function ; each cuneus receiving
impressions, probably through direct fibres, from the homologous half
of each retina on the same side of the median line. Perhaps the first
occipital gyrus should be added to this zone for half-vision. That the
external aspect of the occipital lobes has some relation to vision
is probable, but not yet fully demonstrated in man. The third division
or area of which we have knowledge, a preliminary knowledge only, is
an uncertain portion of the parietal lobe, probably the inferior parietal
lobule, on both sides. This area, we have some reason to believe,
receives and registers impressions of muscular sense, or motor residua.
The first and third of these areas of the sensory zone are fed, like the
motor zone, by branches of the middle cerebral artery, while the second
(cuneus and adjacent occipital gyri) is supplied by the occipital artery,
a branch of the posterior cerebral. Thus, in the sensory zone, we have
a centre for vision, a centre for the audition of language, and a centre
for muscular sense. The cortical connections of the fibres and fasciculi
for common sensibility, for taste, for smell, and for simple sound-hearing
are as yet unknown : perhaps the mesial extremity of the temporal lobes
is the centre for smell. The surgeon can readily expose and treat the
three known centres enumerated above.

Effects or symptoms of tumors in the motor or excitable zone of the
cerebrum. Following the all-important distinction advanced by Brown-
Bequard nearly thirty years ago, and which has been a guide-star to
■■ ssful diagnosticians, we are to distinguish symptoms due to irrita-
tion or excitation of a part from those due to its destruction; in other
words, there are irritative symptoms and destructive symptoms when
a lesion exists and develops in the motor and sensory areas of the
cerebrum.

In obedience to the laws of physiological or functional localization, to
the pathological law of Brown-Sequard, and as we now know from
empirically acquired post-mortem evidence, tumors of the motor zone of
the brain are characterized by a somewhat specific symptom-grouping,
according to the primary location of the growth. Later the symptom-

Ll4 WEIR, SEGUIN, CEREBRAL SURGERY.

group becomes enlarged and obscured by extension of the tumor, its
action upon more than one motor centre, and by more or less direct
effect upon adjacent parts.
I. Tumors of the motor zone.

(a) Tumors of the caudal extremities of the third frontal gyrus (on
the left side in dextrous persons) produce at first slowness of speech and
paroxysmal motor aphasia. Their extension toward the rest of the motor
zone causes paresis and convulsive movements of the tongue, face, and
upper extremity on the opposite side. Later still these symptoms, motor
aphasia, spasmodic movements, and paralysis of the tongue, face, and
upper extremity become more frequent, and, finally, permanent ; with
occasional spasms.

(b) Tumors of the basal ends of the pre- and post-central gyri cause
at first convulsive movements, or paresis, or both, of the opposite half
of the tongue ; later, paroxysmal motor aphasia, spasm, and paresis of
the face and upper extremity ; last, complete paralysis of one-half of the
tongue, of the face, and upper extremity, and permanent aphasia, with
occasional convulsions (" Jacksonian " movements").

(c) Tumors of the caudal extremity of the second frontal gyrus,
where it becomes confluent with the lower third of the pre-central
gyrus, produce at first paresis with convulsive movements (or vice versd)
of the facial muscles of the opposite side ; later, the same symptoms,
with the addition of more or less motor aphasia, paresis of one-half of
the tongue, paresis and spasm of the upper limb (more especially the
fingers); lastly, permanent paralysis of the face, half of the tongue, and
hand, permanent aphasia, and occasional spasms (vide the case reported .

(d) A tumor starting in the lower middle third of the pre-central
gyrus first reveals itself by spasm and paresis of the opposite thumb and
finger (and whole hand and forearm occasionally). After further
growth the irritative and destructive symptoms appear in the face and
tongue, and more or less marked aphasia occurs; the paresis of the hand
and forearm becoming complete paralysis. A peculiarity of lesion of
this centre, not as yet proven to exist in lesion of the other centres of
the motor zone, is a pronounced subjective numbness and slight though
usually demonstrable tactile aniesthesia. This fact, which in its restric-
tion to effects of lesions of the centre for the hand, has been overlooked
or indefinitely treated by authors, is perhaps explicable by that other
fact that the motor education of the hand and forearm is more largely
acquired through conscious sensory impressions. The motor functions
of the tongue, face, and leg. are more automatic in their genesis ; or, in
other words, are performed with much less consciousness of motor effort.
To put it in another way, the delicate movements of the fingen and
hand arc much more sensori-motor, and consciously motor than arc the

WEIR, SEGUIN, CEREBRAL SURGERY. 115

movement! of other museular groups; those of the facial muscles coming
next.

(e) Tumors of the upper middle third of the pre-central gyrus (and
perhaps of the post-central also) early cause symptoms in the muscular
apparatus of the upper arm and shoulder. Later the spasm and paresis
extend to other parts, according as the growth extends ventrad or
dorsad. In the former case the forearm and hand, the face, half of the
toagee, show symptoms, and, lastly, aphasia may occur, though rarely
complete. If the tumor grow dorsad, toward the longitudinal fissure,
spasm and paresis, later paralysis, show themselves successively in the
thigh, K'Lr. and foot.

(/) Tumors of the upper third, or top of the pre- and post-central
gyri, and of the paracentral lobule at first cause symptoms, convulsive
and paretic, in the thigh, leg, or foot. There is every reason to believe
that in man the special subcentre for the hip and thigh is the cortex of
the central gyri where they bend over to form the paracentral lobule,
while the lobule itself innervates the leg and toes. Later, by extension
of the morbid growth, there are symptoms in the arm and hand, rarely
in the face, probably never aphasia (except in the rare cases where a
peculiar vitality of the patient permits of the growth of a colossal
tumor). Or, there may be (though I do not know of any tumor case on
record, yet, at least, one traumatic case exists1) invasion of the crural
centre of the opposite hemisphere, producing paralysis, with spasm or
without spasm, of both legs (pseudo-paraplegia).

These propositions, which are based on the completed study of many
cases of cerebral tumor, have served and will, I think, continue to serve
as safe guides to the diagnosis of the location of a tumor in the motor
zone.

One word as to the local and general spasms which are produced by
lesions thus placed. Usually the first spasm (clonic or tonic) is limited
to a small region, face, hand, arm, shoulder, toe, or leg. The patient is
perfectly conscious and watches the " Jacksonian" spasm with curiosity
or amusement. Subsequently the spasm shows a marked tendency to
extension, in the following serial order: If beginning in the facial
muscles, it extends to the hand, to the arm, and, lastly, to the leg of
the same side. If starting in the fingers, it next affects the face and
upper arm, lastly the leg. When the lesion is on the left side temporary
aphasia is primary, or is superadded according to the exact seat of the
tumor. If the convulsive movements are first shown in the foot, they
nd to the leg and thigh, to the hand and arm, lastly to the face. In
all these mono- or hemi-spasms the movements are irregularly clonic and
tonic, and consciousness is preserved, even when aphasia occurs. If the

1 Macleod : Notes on the Surgery of the War in the Crimea, 1885, pp. 212-16.

116 WEIR, SEGUIN, CEREBRAL SURGERY.

peculiar irritating action continue longer, convulsions appear on the same
side as the tumor and consciousness is lost, showing that the irritation
affects both hemispheres. The fully developed generalized spasms with
loss of consciousness exactly resemble the seizures of so-called idiopathic
epilepsy ; so that the natural history of cerebral tumors shows us in-
sensible transition-forms between the smallest localized convulsions and
typical " epileptic" ones. It is most interesting to note that the results
of physiological experiments upon the motor zones of animals are prac-
tically identical. The serial extension of spasm produced by prolonged
electrical excitation of one motor centre has been determined by Alber-
toni, Luciani and Tamburini, Bubnoff and Heidenhain, Franck and
Pitres, Unverricht, and Rosenbach, from 1876 to 1883. These results
have been confirmed by many subsequent observers, and more especially
elaborated by Franck in his latest work (1887).

It will be noticed that in pathological cases and in experiments the
symptoms, which are due to a small lesion or to a very limited electrical
irritation of a motor centre, are at first restricted to the small muscular
group which this centre controls. This early limited spasm or paresis, I
have long looked upon (even before the physiological demonstration) as
the key to a correct localization diagnosis. It is indispensable to sift
the patient's account of his first symptoms, and obtain the corroboration
of an eye-witness when practicable, in order accurately and positively to
determine the location, nature, and extent of the first symptom, which in
many cases is rapidly overlaid and obscured by others. I propose to call
this the signal-symptom of* cerebral tumor. Since the time of Hughlings
Jackson's first clinical observation to the present time, very numerous
instances of a clearly marked signal-symptom (paresis or spasm) have
been recorded, with the post-mortem proof of its dependence upon a local-
ized lesion in one of the cortical motor centres or associated fasciculi.
Thus, we have all seen cases of cerebral tumor in which the first local-
izing symptom was a spasm or paresis of one side of the face, one hand,
or one leg, and also motor aphasia. I hope soon to present a detailed
study of the signal-symptom of cerebral tumors, its genesis, and extreme
importance for diagnosis.

II. Tumor* of the sensory zone.

Lesions of those areas of the sensory zone whose functions are best
known to us, viz., the centres for hall-vision and for audited speech,
manifest their presence almost exclusively by the so-called destruction
Symptoms. Irritation symptoms probably occur, but we have little
knowledge of them. This subject, might tempt one into a lengthy dis-
cussion, but, on account of want of space, I must limit myself to a bare
statement of the main facts.

(a) A patient presenting, besides the general symptoms of an intra-
cranial growth, such a specific symptom as verbal deafness, without

WKIK, BBGU1N, OEBEBBAL BUBOKBY. 117

narked hemiplegia, hemispasm, or hemianesthesia, probably has a tumor
involving the left superior or dorsal temporal gyrus, or its subjacent
■ whiter i'asriculus. The symptoms produced by extendi; m of this growth
would be mostly sensory, such as paresthesia;, loss of muscular sense,
and later anasthesia of parts on the opposite side of the body.

(6) A patient who has headache, vomiting, choked disk, dulness
tending to stupor, increasing hemianaesthesia, with lateral hemianopsia
(dark half-fields on same side as anaesthesia), without hemispasm or
hemiplegia, quite certainly has a tumor in the white substance of the
occipital lobe.

It', with the above-named general symptoms of cerebral tumor, we
flbd lateral hemianopsia almost alone as a localizing symptom — i. e.,
without hemispasm, hemiplegia, and hemianesthesia — there is almost
certainly a tumor on the inner or mesial aspect of the occipital lobe,
osite to the dark halt-fields, iioilipiwillg and destroying the cuneus.
The symptoms to be expected from the extension of such a tumor are :
from its growth upward, weakness and even paralysis of the lower
i emity of the same side as the dark halt-fields ; and from its down-
ward growth, symptoms of injury to the cerebellum and lobi optici.
That such a diagnostic statement is not fanciful, may be proved by the
findings in the first tumor case operated upon by Dr. AVeir in the spring
of last year.1 The location of this tumor upon the cuneus, or near it, had
been diagnosticated sixteen months before the operation.

Indeed, I am prepared to assert that tumors involving the cuneus, or
ibjacent fasciculus, together with other fibres of the caudal division
of the internal capsule, are now as easy of correct diagnosis as are tumors
of the various motor centres.

Third. The Diagnosis of the Depth of the Tumor.

Equally interesting, and important for successful operative inter-
ference in cases of cerebral tumor, is the question, whether we are now
in a position to tell whether a tumor of the motor zone is cortical
or subcortical — the diagnosis of the depth of the tumor. Let us see
what observations upon tumor cases teach us in this respect. If such a
diagnosis be possible, it will have to be made by a consideration of the
following symptoms :

Nature and location of the signal-symptom, presence, and order

appearance of spasm or of paresis; (b) presence or absence of head-
's (c) changes in local cranial temperatures. The other symptoms
of cerebral tumor are of much more general significance, and cannot, I
think, be utilized for this third diagnosis.

(o) The nature and location of the signal-symptom.

In this connection we can invoke the assistance of physiology, and

1 Medical News, April 16, 1887.

118

WEIR, SEGUIN", CEREBRAL SURGERY.

learn whether experiments show any positive differences between irri-
tation and destruction of the cortex, and of subcortical white substance
in the motor zone. The credit of first demonstrating that convulsive
movements in the opposite limbs may be produced by faradization of
the white substance, after excision of a cortical motor zone, belongs
to Dr. J. J. Putnam, of Boston.1 Since, almost all experimenters have
agreed that faradization of cortical centres, and their subcortical fasciculi,
produces spasm in the parts which the centres innervate ; and even low
down in the internal capsule (Franck, Beevor, and others) the excita-
bility of isolated fasciculi for the tongue, face, etc., can be demonstrated.
We must next ask, Is there any difference in the form or graphic expres-
sion of local spasms produced by irritation of a cortical centre, and that
produced by irritation of its dependent fasciculus after excision of the
cortex ? Here we may hope for a scientific guide in making our third
diagnosis. The latest authoritative answer to this question is to be found
in the remarkable work of F. Franck" on the motor functions of the
brain, published last year. This experimenter has determined the
following important facts, which have been corroborated by other

Fio. 8.

From Franck, op. cit., p. 101. I. Complete epileptiform spasm produced by electrical irritatiou of a
o.iiir.i] motor centre. II. Simple tetanic Bpasm produced by electrical irritation of subjacent white
fasciculus. E, E., duration of electrical application. T, tetanic or tonic spasm. Ep, clonic or epilepti-
form spasm. 0, absence of spasm.

observers in certain directions. 1st. There is greater "delay" in the
occurrence of muscular contraction after the application of the electric
current to the cortex, than there is when it is applied directly to
subjacent medullary fasciculi. 2d. Electrical excitations of the medul-
lary fasciculi produce only tetanic contractions, owning abruptly, or
nearly so, when the excitation stops. When the motor cortex il

> Boston Med. and Surg. Journal, July, 1874.

* Op. cit., pp. 09-100.

WEIR, BIOU1K, CEREBRAL SURGERY. 119

ited, however, we obtain a tetanic (or tonic) contraction while
the current passes, lasting a little while after it ceases, and followed
"by clonic convulsive movements; in other words, an epileptiform con-
vulsion. Consequently, Franck proposes the following law: "The
hemispheric white substance, in the centrum ovale, or in the internal

~ile, is devoid of epileptogenous property, whereas the cortex above
possesses this property." (This applies, of course, only to the cortex
and white substance of the motor zone.)

Does the study of cases of lesions of the human motor cortex and
associated fasciculi furnish corresponding data for diagnosis? We must
answer, No. The types of spasms observed in cases of cerebral tumor
are constantly variable in the same subject. We obtain simple tonic
seizures, tonico-clonic and clonic spasms are observed, as well as typical
epileptic attacks commencing by tonic spasm of a small part (signal-
symptom). Further study of these phenomena may throw more light
upon the differential diagnosis between cortical and subcortical tumors ;
but we must not be too sanguine in this matter, because a source of con-
fusion will always exist in such cases, viz., that in cases of subcortical
tumor the cortex governing the affected fasciculus is still present and
active, and that the irritation of the tumor may act both centripetally
and centrifugally. In the former case the irritation of the tumor would
produce "discharges" or spasm dependent upon cortical irritation (true
epileptiform attacks), while in the latter case simple tetanic or tonic
spasm due to excitation of the medullary substance alone would appear.
It is highly probable that in human subjects this twofold excitation takes
place, thus explaining the complicated and variable spasmodic move-
ments which are observed. We conclude that at the present time it is
impossible to distinguish a cortical from a subcortical tumor by the
character of the convulsions observed.

Turning to the purely clinical and empirical aspects of this question, let
■■' what authorities say. The great majority of recent writers upon
nervous diseases do not even attempt the diagnosis of cortical from sub-
cortical lesions. Among these are (in chronological order) ; Charcot,1
Pitres,5 Wilkes,5 Grasset,* Hammond,5 Ross,' Strumpell,7 Webber/
Bastian,' Liebermeister,10 Starr,11 Jastrowitz,1'-' Wood," Seeligmuller,"

1 Lemons sur 1m Localisations dans les malndi»-« du cerveau. Paris, 1876.

* Recherches sur les lesions du centre oTale, etc. Paris, 1*77.

* Lectures on Diseases or the Nervous System. London, 1878.

4 Traite Pratique des maladies du systeme nerveux. Paris, 1881.

* A Treatise on the Diseases of the Nervous System. Seventh ed. New York, 1881.

* A Treatise on the Diseases of the Nervous System Amer ed. New York, 1881.
i Lehrbuch der speciellen Pathologie u. Therapie, Bd. ii. Leipzig, 1884

» A Treatise on Xerrous Diseases. New York, 1885.

* Paralyses, Cerebral, Bulbar, and Spinal. Amer. ed. New York, 1886.

10 Vorleeungen ttber specielle Pathologic u. Therapie, Bd. ii. Leipzig, 1886.

» Intracerebral Tracts. New York Medical Record, 1886, i. 174.

" Deutsche med. Zeitung, 1887, p. 1098. 1J Xerrous Diseases. Philadelphia, 1887.

14 Lehrbuch der Krankheiten des BUckenmarks unl Gehirns, Abth. ii. Braunschweig, '

120 WEIR, SEGUIN, CEREBRAL SURGERY.

Gowers.1 Several of these authors, however, give some data bearing on
this diagnosis, Gowers stating that lesions of the white substance give
rise to local convulsions only when they are situated immediately under
the cortex. The following authors discuss the problem more or less:
Nothnagel,2 Bernhardt,* Osier,* Mills and Lloyd.5 The first author of
the second series treating of lesions of the centrum ovale, more espe-
cially of clonic spasms produced by them, says : " They are similar in
their characteristics to those which are produced by cortical lesions;"8
that they may be limited to one member permanently, or may begin
in one member and extend to others on the same side of the body with-
out loss of consciousness. If the convulsions pass over to the other side,
consciousness is lost and the attack resembles an attack of epilepsy. Yet
the author has never seen a case in which a strictly subcortical lesion
produced hemispasm, and he considers Pitres' seventeen cases as all
open to criticism. He considers it doubtful if a truly subcortical lesion
can produce monospasm or hemispasm. His third law relative to lesions
of the centrum ovale is substantially as follows : Even if focal symptoms
are present, it is impossible to conclude that there is a lesion limited to
the white substance, as these symptoms are identical with those produced
by lesions of the corpora striata and of the cortex. In other words, the
diagnosis of a medullary lesion is at present impossible (1879).7

Bernhardt,8 speaking of tumors in the white substance of the parietal
lobes (including the motor gyri), states that in fifteen out of twenty-nine
cases convulsions, local or general, occurred. In the cases of local spasm,
paralysis preceded or followed the spasm. The symptoms of this class
exactly recall those observed in connection with cortical tumors.

In another place9 he repeats that subcortical and cortical tumors of
the parietal lobes (which include the central gyri) produce similar motor
symptoms, viz., local convulsions preceding or succeeding paralysis. The
differential diagnosis is extremely difficult.

Osier10 reports a case of tumor under the paracentral lobule, which
comes nearer to meeting the requirement of a test-case. The growth
was found mostly in the white substance; its size was 17 by 15 mm. ;
it was distant 8 mm. from the left paracentral gray matter, 10 mm. from
the top of the brain, and 15 mm. from the central gyri, but the tumor
touched the gray matter at several points. The signal-symptom was a
spasm, limited to the right extremities, first in the arm, second in the

1 A Manual of Diseases of the Nervous System, vol it. London, 1888.

* Toplsche Dlagnoetik der Qohirnkrankholten. Berlin, 1870.

* Symptomatologie u. Diagnostik der llirngeschwtlNt . Ilerliu, 1881.

* Medical News, January 10, 1884.

* Pepper's System of Medicine, art. Tumors of the Brain, vol. v. Philadelphia, 1886.

* Op. cit., p. 378. ' Nothnagel : Op, i it., p. 377.

* Op. cit , p. 128. » Op. cit., pp. 131, 132.
10 Medical News, PhiU . .Innmirv It, 1884.

WEIR, SEQUIN, CEREBRAL SURGERY. 121

leg, and last in the face. Paresis followed. In its early period this
growth was probably strictly medullary.

Mills and Lloyd1 express themselves more fully. "As the white mat-
ter of the centrum ovale and capsule represents simply tracts connecting
cerebral centres with lower levels of the nervous system, with each other,
or with the opposite hemisphere, lesions of this portion of the cerebrum
will closely resemble those cortical lesions to which the tracts are re-
lated. Those (lesions) situated in the white matter in close proximity
to the ascending convolutions give symptoms closely resembling those
which result from lesions of the adjoining cortical motor centres. In the
cases of Osier, Pick, and Seguin, paretic symptoms in the limbs of one
side of the body, with or without loss of consciousness, were marked
symptoms. In two of these cases some paresis preceded the occurrence
of the spasms. They did not, however, fully bear out the idea of Jack-
son that the hemiparesis or hemiplegia in tumors of the motor tract
comes on slowly before the appearance of spasm."

Hughlings Jackson* has placed on record a case which overthrows
the dictum that tumors of the cortex invariably produce convulsions
fir.-t. Case of traumatic external tumor on left side of the head of
eighteen years' standing. Six months before observation severe local
pain appeared in this region, and there developed a gradually increasing
paresis of the right leg, arm, and face (in order) ; optic neuritis ; but no
convulsions. The autopsy showed an internal tumor pressing upon the
motor zone. Jackson adds : " In all cases of very slowly coming on
hemiplegia I have seen, the tumor has always been of (in) the motor
That disease of the surface — even very limited disease thus
placed — will cause hemiplegia, is well known, and is illustrated by
ral cases of this series ; but in all cases seen save this one, the hemi-
i] lowed a convulsion." Consequently it appears that Jack-
son, in ls74. . »nsidered it a law that cortical lesions produced convul-
sions first, paresis second.

In my own records I find the following data in three cases of cortical
and one of subcortical tumor. In the subcortical tumor,3 which was
just beneath the top of the central convolutions, latero-dorsad of the
paracentral lobule, paresis preceded spasm. In the case we present,
on the contrary, spasm preceded paresis.* With respect to the three
cases of cortical tumor of the motor zone, in one,5 local spasm proba-
bly preceded paralysis ; in the second,* paresis and spasm appeared simul-

I Op. cit , p. 1059. * Medical Times and Gazette, 1874, ii. 152.

* A Third Contribution to the Study of Location of Cerebral Lesions, Journal of Xervous and Mental
Diseases, June, 1887.

4 It U doubtful if this tumor was, strictly speaking, subcortical.

* Contribution to the Study of Localised Cerebral Lesions, Seguin's Opera Minora, p. 215, New
York, 1884.

* Second Contribution to the Study of Localized Cerebral Lesions. Idem, p. 405.

122 WEIR, SEGUIN, CEREBRAL SURGERY.

taneously in the left hand ; and in the third,1 monospasm occurred
first. These five cases, and other cases by different authors, bear out
the preceding statements that, at present, no law of motor symptoms
can be formulated for cortical and subcortical tumors.

(b) Can the cortical or subcortical location of a tumor be determined
by the presence or absence of localized headache? There has long
existed a somewhat well-founded notion that lesions of the brain are
more painful in proportion as they are nearer to the dura mater. Yet
a study of recorded cases of tumor go to show that such remarkable
exceptions occur, that the rule is not one to be depended upon, though
it has a certain corroborative, or secondary value. Only a few cases
need be cited.

In Osier's2 case of subcortical tumor headache is not mentioned, while
in the case of Baudot (cited by Pitres3) of a tumor in the middle portion
of the centrum ovale, with symptoms of lesion of the motor zone, severe
headache was an early symptom. Russell* reports a case of cancerous
tumor of the right frontal lobe, involving both white and cortical gray
substance, in which " slight headache" occurred, and Hughlings Jackson5
publishes a case of tumor compressing the cortex of the motor zone, in
which severe local pain (not a common headache) was a marked symp-
tom during the first six months.

Bernhardt6 states that headache was positively absent in 2 out of 36
cases of tumor in the white substance of the frontal lobes, aud in 3 out
of 29 cases of tumor in the parietal lobe. As regards the medullary
substance of the occipital lobe, there is no observation in which it is
stated that headache was absent, but in 4 out of 15 cases pain is not
mentioned among the symptoms. He considers pain as a symptom of
no special value for localization ; it may even be on the side opposite the
tumor.

Perhaps a more certain indication is the presence of tenderness to
percussion. A case seen by me last autumn, in consultation with Dr.
Obendorfer,7 well illustrates the small value to be attached to these two
symptoms. A man, set. fifty-six, had suffered from obscure urinary diffi-
culties, including hsematuria; a few months before death he developed
symptoms of cerebral compression, headache, drowsiness, slow pulse, but
no choked disk. For several weeks the head-pain was localized over the
right frontal region, in a space about four centimetres (U inches! in
diameter. This region was also tender when I saw the patient. Surface
tciii]>erature carefully taken with an Immich metallic thermometer, gave
on right frontal bosse 96.5°, on the left 97°. Consequently, the sensory

i Idem, p. 400. t Medical News, Philadelphia, January 19, 1884.

* Lesiuns du centre oYale, ; * Med Time* and Oazette, 1874, i. p. 630.

» Op. cit. • Op. cit.
» Cited with Dr. Wiildstein's permission.

WEIR, SEGUIN, CEREBRAL SURGERY. 123

■ymptoms, together with the absence of hemispasm and hemiplegia, of
hemianopsia, were in favor of the existence of a tumor on or in the right
frontal lobe ; though the absence of increased local temperature argued
Otherwise. The autopsy made in December, 1887. by Dr. Waldstein
showed a large cancerous tumor of the kidney, and two secondary tumors
in the brain ; one in the right temporal, the other in the right occipital
lobe. There was no lesion of any sort in the right frontal region.

In view of the utter conflict between these observations by reliable
authors, I think it unnecessary to quote more. The conclusion is evi-
dent that pain and tenderness are symptoms of wholly secondary value
tor localization purposes.

(c) Do variations in the local cranial temperature help us? Here we
obtain a qualified negative answer. The normal average tempera-
ture at the various "stations" is widely different, according to first-rate
observers (Broca,1 L. 0. Gray,- Maragliano and Seppilli3). Observa-
tions of cranial temperature have been recorded in only four cases of
cerebral tumor (to my knowledge), besides the case reported, and the
results would seem to indicate that there is sometimes a rise of cranial
temperature over the site of the tumor. In our own case the results are
irregular and inconclusive. It may be objected that better results would
be arrived at by using the thermo-electric differential calorimeter of
Lombard, but if great variations occur when measurements are made in
fifths and tenths of a degree, how much greater would be the irregularity
and uncertainty of results measured by one five-hundredth of a degree,
one two-hundredth, or even by one-hundredth. The fluctuations and
variations would necessarily be enormously increased by using the more
-itive instrument.

A summary of Gray's normal cranial temperatures, and the full data
of the temperature in four cases of intracranial tumors, will be found in
Pepper's System of Medicine, vol. v. pp. 1036-7, together with some
bibliographical references.

Writing in 1886/ Dr. M. Allen Starr states his conclusion to be in
complete accord with Xothnagel's in 1879, viz., that "there are no diag-
nostic local symptoms of lesion of the centrum ovale."

Still, as regards the motor zone, in which, as a rule, it is usually
possible correctly to localize a tumor, the question is somewhat simpli-
fied, and may be stated as a diagnosis of probability, with many chances
of error. In favor of a strictly cortical or epicortical lesion are these
symptoms, none of them having specific or independent value: Localized
clonic spasm, epileptic attacks beginning by local spasm, followed by

1 Thermometri- tVr.brale. Berne Scientifique, September, 1877.

* On Cerebral Thermometry. Journal of Nervous and Mental Disease?, July, 1878.

3 SI l Wl 0|iM tMWitlll 'li Freniatria, etc. Anno V. fascic Land II. [Alienist and Neurologist, 1.1880. ]

t Intracerebral Tracts : New York Medical Record, 1886, I. 174.

TOt 97, !«0. 2.— AUGUST. 1888. 9

124 WEIR, SEGUIN, CEREBRAL SURGERY.

paralysis; early appearance of local cranial pain and tendern<
increased local cranial temperature. In favor of subcortical location of
a tumor : Local or hemiparesis, followed by spasm ; predominance of
tonic spasm ; absence, small degree, or very late appearance of local
headache, and of tenderness to percussion ; normal cranial temperature.

In the case reported by us this evening, this question was discussed
by Dr. Weir and myself. We were not unprepared to find the cortex
normal, because the late appearance of headache, the absence of con-
stantly increased temperature over the supposed site of tumor, pointed
to a subcortical tumor.

The exact location of the growth in the case reported cannot now,
and perhaps never will be accurately stated. My belief is that it was
in close relation to the gray matter deep in the sulcus which separata
the second and third frontal gyri. But for surgical purposes, it was a
subcortical tumor. No sign of it appeared on the surface of the brain,
and the depth of the cavity left by its removal was estimated by Dr.
Weir at about one and a half inches.

Fourth. The Diagnosis of the Solitude of the Tumor.

The surgeon's decision to operate, and the probabilities of his suc-
cess, will depend very much upon the presence of but a single tumor
in the brain. Can we diagnosticate multiple cerebral tumors? To this
question a qualified affirmative may be given.

When the symptoms of cerebral tumor occur in an individual who
already bears a tumor or presents signs of tuberculosis, the probabilitie.-
that the cerebral secondary deposit is multiple, will be very great, and
for this and other considerations an operation will be unadvisable.

When symptoms indicating lesions of different cerebral centres or
systems are present, and especially when the symptoms of basal disease
are combined with those characteristic of tumor of the motor or sensory
zones, the probability of double or multiple lesion will be so great as to
amount almost to certainty. For ^example, should a patient present
motor symptoms in one hand and side of face, spasm and paresis, with
liradache and perhaps choked disk, justifying the diagnosis of tumor in
the precentral gyrus; if in such a patient marked anaesthesia, or hemia-
nopsia, or verbal deafness should develop, we would have reasonable
ground for suspecting the presence of another tumor (or of several
tumors) involving the posterior division of the internal capsule in the
occipital lobe, or the left first temporal gyrus. Or, if in :i patient with
symptoms of tumor in the precentral gyrus, there should supervene
marked dysphagia and dysarthria, symptoms of irritation or paralysis
of the pneumogastric and spinal accessory nerves, with bilateral pal
of the extremities, the presence of an additional growth in or on the
medulla oblongata may be diagnosticated. This waa the case of a giri

WEIR, SEGUIN, CEREBRAL SURGERY.

125

observed some years ago at my clinic for nervous diseases of the College
of Physicians ami Surgeons, by Dr. W. R. Birdsall and myself. The
main tumor was found at the autopsy to have been correctly localized;
but there were several others in the brain, one of them in the very
O ntre (uthe medulla oblongata, explaining the bulbar symptoms which
closed the patient's life.

This problem of recognizing growths which are distant from one
another, and which affect different systems of fibres and different ganglia
of the encephalic mass, is relatively simple, though, of course, not always
ed during the patient's life.

Fiq. y.

Fig. 10.

Fig. 9 —Diagram of convexity of brain, showing location of the (subcortical) tumor, r. Frontal
end of trail ; o. occipital end.

Fig. 10. — Diagram of transection of left hemisphere, showing position of tumor, and of two minute
secondary growth*.

A much more obscure form of multiplicity of cerebral tumors is
when more than one growth exists in one system or zones close together.
These cannot, I believe, by any possibility be recognized during the
patient's life, and may also escape observation at the time of the
operation.

This unexpected complication is illustrated by the appended diagrams
(Figs. 9 and 10), which represent the location of a sarcomatous tumor of
the leg-centre, reported by me last year before the Association of Ameri-
can Physicians, in Washington.1 This tumor was correctly diagnosticated
during life, in 1881, before the idea of operating for tumor of the brain
had been advanced. The transverse section shows, besides the main

1 Journal of Nervous and Mental Diseases, June, 1887.

126 WEIR, SEGUIN, CEREBRAL SURGERY.

tumor, which could have been removed most easily, two small secondary
growths deeper in the white substance, M'hich, had an operation been
attempted, would probably have been overlooked.

This difficulty is one which ought not, in my opinion, to weigh much
against operating in well-defined cases ; it is one of the unavoidable bad
chances of the operation.

Fifth. The Diagnosis of the Nature of the Tumor.

In some cases this is all important, as a negative element, in deciding
for or against an operation. For example, in cases of tuberculosis of the
lungs or other organs, or of general tuberculosis, if symptoms of brain-
tumor present themselves, it is extremely probable that this cerebral
growth is a tubercle or that there are several tubercles. It is certainly
undesirable to interfere in such a case.

In a second category of cases, coincident with a recognizable cancerous
tumor of external parts or of internal organs, symptoms of intracranial
tumor appear. Here, again, the probability of multiple cerebral growths
and the fact that other organs are affected with an incurable disease should
lead to a refusal to operate. In other cases the cerebral symptoms occur
after the extirpation of the peripheral tumor, but the contraindication
remains quite as strong, because of the probability of multiplicity.

In a third set of cases we have every clinical reason for believing that
a gumma or several gummata are in the brain producing the symptoms.
Here, again, the objection of probable multiplicity of growths exists, but
it is not as imperative as in the two preceding categories.

Hale White,1 of London, in a recent excellent study of one hundred
cases of cerebral tumor with respect to the feasibility of an operation,
has expressed the opinion that gummata should not be operated, and
Prof. Bergmann, of Berlin,2 who has also written upon cerebral surgery
last year, criticises Horsley for having operated on such a tumor. We
must take exception to both White's and Bergmann's diet a as not based
upon a proper consideration of the natural history of gummata. One of
the peculiarities of these feebly nourished, degenerative growths is their
tendency to persist as inert tumors, yet acting as foreign bodies, after most
thorough specific treatment. Of course, a gumma of the brain should
not be sought for by surgical methods before every medicinal means has
been used. A thorough anti-syphilitic treatment with mercury, ami
especially with the iodide of potassium administered according to the
American method,3 should be carried out for a long time. If, alter this
had been done for several months, the localized spasms and paresis, and
perhaps other symptoms of looalizable cerebral lesion exist, an operation

i Guy'i U<»|>itiil K. |*»rt*, v.. I. xliii. 1885-6.

* Die chirurglaclie Behantlliing mn llirnkranklioitiii. Anliiv f. klin. Cliiiurgie, xxxvi., 1888.
■ Tli' \in.ri.ini IMth0d of gtrlag pOWWhll u»l..|.- in very large dixies, etc., AlOhlTM of MediciM
1884.

WEIR, SEGUIN, CEREBRAL SURGERY. 127

■ ..rtainly justifiable. An inert, degenerated gumma in the cortex of
the motor zone will, I believe, continue to cause discharging symptoms
indefinitely. Against this action further anti-syphilitic treatment is
useless, and the continued use of bromides only postpones and reduces
the discharges. Besides, if nerve-tissue is compressed by such an inert
tumor so as to cause paresis, its recovery is impossible until the pressure
is removed by surgical interference. While acknowledging, therefore,
that probable multiplicity is an objection to operating for gumma of the
brain, I think the operation desirable, in well-selected cases, after a
thorough medicinal treatment has been carried out.

The diagnosis of all other forms of intracranial growths is most
ure, and we can only be guided by statistical results as to the abso-
lute and relative frequency of the varieties of tumors, and it should be
l> true in mind that the deductive application of such data to a case in
hand is extremely uncertain — almost mere guesswork.

The statistics which can be best utilized for such a purpose are these
of Bernhardt and Hale White, which probably contain few if any dupli-
I rases. The cases of intracranial tumor which have been published
siine the date of Bernhardt's monograph (1881) excepting White's cases
56), would doubtless be considerable, and very instructive, but we
have had no time for such a bibliographical labor. Bernhardt and
White together tabulate 580 cases, which can be grouped as follows:

Xs ruber. Percent

Nature of tumor not stated 133 22 9

Tubercular tumors 137 23

<Hiomata 76 13

>mata (including cysto-sarcoma) . . . 70 13

Hydatids, cysticerci, and echinococci . . .30 5

s 27 4.6

Carcinomata 24 4

Gkunmata 21 3.6

Glio-sarconiata 14 2.2

Myxomata (including myxo-sarcomata > ... 12 2

Osteomata .........6 14-

Neuromata 4 — 1

Psammomata 4 — 1

Papillomata 4 — 1

Fibromata 3

Cholesteomata 2

Lipomata 2

Erectile or vascular tumors 2

Dermoid cysts 2

Enchondromata 1

Lymphomata 1

Cases ... .380

128 WEIR, SEGUIN, CEREBRAL SURGERY.

Few remarks are required as comments upon this statistical state-
ment.

(1) The frequency of cysticerci, echinococci, and hydatids in the con-
tinental (German) records (no cases appearing in White's list of 100
cases), must be attributed to dietetic conditions. In this country, such
growths are, as in England, almost unknown.

(2) The cerebellum appears most prone to cystic formation, often as a
secondary development from a sarcomatous tumor.

(3) The average age at which most sarcomata and gliomata occur is
almost the same —between thirty and forty years.

(4) Slow development of symptoms is in favor of sarcoma.

A fair general conclusion to be drawn from the above data is, that the
surgeon must be content to have the physician furnish him with a posi-
tive diagnosis of intracranial tumor, with a reasonably exact diagnosis
of the location of the tumor, and with a probability diagnosis of its
solitude. Except in cases of secondary new-formation (in which an
operation is almost positively contra-indicated), and in cases of cerebral
gummata, the diagnosis of the nature of the tumor, and of its encapsu-
lation or infiltration, should be withheld.

I may be permitted to add a statement of my own estimate of the
advisability of operating for the removal of a cerebral tumor. Assuming,
with Lucas-Championniere, Weir, and others, that the operation of tre-
phining in itself is now almost without danger, I would still restrict
surgical interference to cases which present well-defined indications.
This remark is, however, not applicable to certain cases of epilepsy fol-
lowing injury to the cranium, of inveterate fixed cranial pain, etc., where
an exact medical diagnosis is not possible, yet in which the surgeon may
consider an exploratory trephining desirable — with the explicit under-
standing as to the purpose of the operation. There appears to prevail a
tendency to indiscriminate operations on the brain, which is to be depre-
cated, because it tends to bring into discredit a therapeutic resource which
now offers some little hope of cure in otherwise fatal cases, and which
may in the future yield still more satisfactory results.

WILLIAMS, TLEATMENT OF BRONCHIAL ASTHMA. 129

THE TREATMENT OF BRONCHIAL ASTHMA.
By C. Theodore Williams, M.A., M.D., F.R.C.P.,

PHYSICIAN TO THE HOSPITAL FOE CO!tSCMPTI«N AND DISEASES OP THE CHEST, BROMPTO.N.

Tm pathology of asthma has been warmly discussed, and various
theories have been suggested to explain the phenomena of the nocturnal
seizures and their recurrence, but a careful survey of the facts has con-
vinced me of the truth of the nervo-muscular origin as put forth by
( '. J. B. Williams, Hyde Salter, Biermer, and Thorowgood, as it is
the only theory that affords explanation of (1st) the fitfulness of the
dyspnoea; (2d) of the ever-changing physical signs, and especially of
the rapid appearance and disappearance of sounds within the thorax ;
and (3d) of the remarkable influence of certain therapeutic agents on
the spasmodic attacks.

Having discussed the pathology of asthma elsewhere,1 I will confine
my remarks in this article exclusively to its treatment, introducing only
si . much of the pathology as is necessary for illustration ; and as we have
arrived at the conclusion that bronchial asthma is a neurosis chiefly
affecting the pulmonary plexus, and spreading through its various
connecting branches, and thus implicating the pneumogastric, spinal,
and sympathetic nerves, we have to consider the best means of allaying
such nerve storms. As in the case of all neuroses, we are met with
many difficulties, arising for the most part from individual idiosyncrasies.
The medicine which suits one patient does not suit another, and the
climate that cures an attack in one, appears to produce it in another, so
that many investigators give up the search after a scientific basis for
treatment of bronchial asthma in despair.

There are, however, practical rules and indications if we take the
trouble to study them, and they appear to be the following :

'. To counteract, if possible, the tendency to asthmatic attacks,
which arises generally from some definite lesion the result of a former
inflammatory attack.

Second. To allay, and keep allayed, the asthmatic spasm ; this is
principally done by removal of the patient from the various exciting
causes of the attack, but also by reducing the sensibility of the pulmo-
nary plexus of nerves.

Now, in dealing with the first, we must note that, according to Hyde
Salter, no less than eighty per cent, of asthma is traceable to bronchial
inflammation in childhood, following on whooping-cough, measles, bron-
chitis, or broncho-pneumonia, and in adults it often follows upon phthisis.

i Article " Asthma," Quain's Dictionary of Medicine. "Lectures on Spasmodic Asthma," Lancet,

130 WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA.

The most probable cause of this sequence is that all these diseases give
rise to swelling of the bronchial glands, the position and relation of
which are too little studied in thoracic pathology. They have been
admirably delineated by the late Noel Gueneau de Massy,1 and his
pupil Barety,2 the latter of whom classified them, and demonstrated
their exact relation to the pneumogastric nerves, and to the sympathetic
ganglia. Careful study of these will show that it is impossible for
enlargement of the subtracheal glands to take place to any large extent
without causing pressure on the vagi and their branches. It is rare for
the pressure to be great enough to give rise to ulceration of the trachea
or bronchi, though this occasionally takes place, as was seen in some
cases of Percy Kidd,8 but considerable enlargement of the bronchial
glands at the root of the lung is by no means infrequent, and may be
detected by physical signs, which consist generally of dulness in one or
both interscapular or suprascapular regions. The swelling of the large
glands of the anterior mediastinum may be detected by the presence of
dulness over the first portion of the sternum.

Now, we know that the preparations of iodine are singularly effica-
cious, both in reducing the frequency of asthmatic fits, ami also in
causing the absorption of lymphatic glands, if administered in suffici-
ently full doses, and it is probable that this last effect is the explanation
of the first one.

A medical friend once said to me, " I never give up a case of asthma
until I have tried ten grains of iodide of potassium three times a day.''
It is indeed wonderful how this salt reduces the frequency of the attacks.
In some cases it undoubtedly produces iodism, though not immediately,
but the evil day may generally be postponed by largely diluting the salt
with water. Some patients never derive benefit from it unless they feel
the commencement of iodism. A late well-known physician, ami a
martyr to asthma, told me that he used to take potassium iodide until
the metallic taste appeared in his mouth, which he always found was
accompanied by secretion from the bronchial tubes, and at once relieved
the spasm.

In one severe case, where the large doses were followed in forty-eight
hours by an eruption of acne over the face, the patient, a lady, told me
that she did not obtain relief until the spots appeared, and she gladly
endured them to secure freedom from the asthma.

The iodide of potassium appears to be far more effective in doses of
from gr. viij to gr. xv than in the smaller ones of gr. ij to gr. v, and at
the same time the larger dose does not appear to increase the risk of

i Gazetta de* Hopltaux, 1867 and 1808.

* L' Adenopathy Trachoobronchlque. See *1*> Quain'n Dictionary of Modiclne, " Disea- ■■:' Hi n-
cutal Gland*."

* Pathological Transaction*. 1-

WILLIAMS, TREATMENT OK BRONCHIAL ASTHMA. 131

iixlism, provided, always, that plenty «>f water be taken with it. Patients
often take gr. viij to gr. x two or three times a day for months, and one
patient of mine persevered for two years, with tin- only drawback of an
■none! rash of urticaria and a metallic taste in his mouth. By this
moans he was kept entirely free from asthma.

Three of the most obstinate cases of bronchial asthma that I ever came
across, in all of whom the attacks were accompanied by lividity, were
by this means relieved so far that they could control the seizures suffi-
ciently to attend to their business, and oue of the three was completely
cured.

The iodide of sodium may be substituted for the iodide of potassium,
but the dose is smaller (about five grains), and a combination of the two
iodides is ofte,n desirable.

Various mineral waters containing iodine in some form exercise a
favorable effect on asthma, but are slower in their action. Such are
the Woodhall and the Purton, in England, and the waters of Kreuznach,
in (. Germany. Some people, however, are so susceptible to the action of
iodine that a few glasses of Woodhall water, which contains one-fourth
of a grain of iodide of sodium in a pint, will produce iodism, as I noted
in the case of a well-known physician who tried it for asthma.

The inunction of the ointment (unguent, potassii iodidi) or of the
liniment (lin. potass, iodidi c. saponi) or the painting of the skin with
tincture of iodine has never, in my experience, produced the same
therapeutic effect on the asthmatic attacks.

The indications for prescribing iodide of potassium or the above-
mentioned waters are (1) the absence of catarrh and bronchitis, (2) the
well-marked presence of the neurotic element, and (3) the detection of
dulness along the right or left edge of the first portion of the sternum,
or in one or both interscapular regions, showing enlargement of the
bronchial glands. Another medicine of great use in reducing the predis-
position to asthma is arsenic, and it may with advantage be combined
with the iodides. This and the mineral waters of La Bourboule and
M it Dore\ which contain arsenic, seem to act in some way as a tonic
to the respiratory functions and to strengthen the controlling or inhibi-
tory element of the nervous system of the lungs.

Free sponging in a bath with tepid or cold water every morning, to
which sea salt may with advantage be added and a careful dietary,
which we will discuss presently, may do much to keep off the attacks of
asthma.

The treatment of the attack generally resolves itself into the adminis-
tration of antispasmodics, which may be classified as stimulant and
sedative. Brandy and water, whiskey and water — best administered
warm, hot strong coffee, spir. setheris (in drachm doses), and inhalation
of nitrite of amyl are examples of this first class, and appear to act by

132 WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA.

promoting large bronchial secretion and expectoration, but the nitrite
of amyl, which is said to influence the vasomotor system and to relax
the arteries, has not been successful in my hands in asthma.

The sedative class of antispasmodics has much greater claims on our
notice, as several of them, such as belladonna, stramonium, and henbane,
have been indicated for use by the experiments of C. J. B. Williams
in 1840, who found that, in animals poisoned by those drugs, the bron-
chial tubes were dilated, and incapable of being excited by any stimulus.
and abundant clinical evidence has proved their efficacy in reducing
the asthmatic spasm, but the difficulty lies in applying them at all times
to the lungs, and bringing the pulmonary plexus and bronchial muscle
fully under their influence.

The popular method of smoking them in cigarettes, or inhaling the
smoke of deflagrating powders or pastilles, composed of the dried leaves
of datura tatula, or datura stramonium, or lobelia, or belladonna, and
nitrate or chlorate of potash, is useful up to a certain point, but in my
experience the effect is more certain and stronger when the medicinal
agent is taken into the stomach, or injected under the skin, and although
use may be made of the various fuming powders for temporary relief,
reliance should chiefly be placed on medicines containing the antispas-
modics ; as it would seem probable that the products of combustion of
a plant must differ greatly from its natural juices, and sap carefully
extracted, as is now done by pharmacy, and consequently exercise a
different effect on the system.

The best way is to combine the stramonium, belladonna, or henbane
in the form of succus or tincture, with the iodide of potassium, to be
taken during the day, and to administer a pill of extract of stramonium
(gr. i), or belladonna (gr. i), at night during the attack.

A useful form is the following :

Potassii iodidi 3>j to 3iij-

Tinct. 8tramonii 3ij to oiij.

Syrupi scillse 3j-

Extract, glyeyrrhiza? .ij.

Aquoe ad ,^viij.

Dose. — A tablespoonful in a wineglass of water, three times a day.

Of the various sedatives to be used during the attack, chloral i> one
of the safest and best, but a dose of from gr. xx to xxx should be
administered at the beginning of the attack, or, if there be premonitory
symptoms, before it has actually commenced. A dose at bedtime will
often enable an asthmatic to sleep through slight early morning sci/uns.
and this medicine will, if pushed strongly, control the asthma. In one
nxst obstinate case under my care, it was administered in gr. xx doses
every four hours for several days, and allayed the severe spasm, hut

WILLIAM.-. TREATMENT OF BRONCHIAL ASTHMA. 133

induced vomiting and an eruption of purpura. Another asthmatic,
who can always keep his asthma at bay by hard riding during the
hunting season, has taken chloral during the rest of the year in doses
of gr. xx to gr. xxx during his frequent attacks, with no harm what-
ever, for about ten years. My experience with chloral, which I adopted
from Professor Bienner's practice, has, on the whole, been highly satis-
factory, and I consider it one of the most useful and least harmful of the
sedative antispasmodics.

When the paroxysm is very severe, chloroform, or ether, or iodide of
ethyl may he inhaled, and Martindale's capsules of chloroform ("ix),
and iodide of ethyl i "liij to "tv), are specially well adapted to the
purpose, as being tolerably safe to entrust to nurses and to patitnts.
Iodide of ethyl can be inhaled up to rt^x, and the inhalations even
repeated at the end of two hours without danger, and while it quiets
the asthmatic spasm, it also calms the cough which accompanies it. In
the height of the paroxysm the patient can neither swallow nor inhale,
and it is then that the hypodermatic injection of morphia (gr. i) or of
atropia (gr. -£$), or of both combined, does great good, and often cuts short
the attack at the very beginning. Another channel for introducing
antispasmodics is the rectum, and suppositories of morphia or belladonna
have often succeeded in relieving the tightness of the breathing when
other measures were impracticable. With regard to the numerous
powders, cigarettes, and tablets, if any distinction is to be made, I should
certainly single out Himrod's powder (lobelia, stramonium, tea, and
nitre), the Green mountain cure (also lobelia, stramonium, tea and
nitre, in different proportions to the Himrod), and Senier's powder,
ry & M«>ore's tablets, and the pulv. stramonii comp. of the Brompton
Hospital pharmacopoeia,1 as the most effective. Among the cigarettes,
Espic's and Joy's do most good, and all contain large proportions
of stramonium and lobelia. Even tobacco-smoking gives relief, and
Trousseau was able to control his own slighter attacks completely
thereby. The application of stimulating liniments, such as lin. terebinth,
aceticum, or lin. ammoniae, to the wall of the chest, during an attack,
often gives great relief to the breathing, and is well worth a prolonged
trial.

One old-fashioned but very effective antispasmodic has been omitted,

the ethereal tincture of lobelia, and it should certainly be tried, but in

full doses, say of a drachm, and repeated every four hours while the

spasm lasts. The various bromides, of potassium, ammonium, and

im, are useful in large doses, but their influence on the pulmonary

"» Jk. — Pulveris stramonii 3i».

Pulreris anisi,

Pul veri» poteaeii nitrat is aa 3ij.

PnWerie taWi gr. t.

134 WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA.

plexus is not so satisfactory as that of the iodides, though they may
often be combined with these advantageously, and the addition of ■
drachm of the bromide of potassium to the chloral night-draught gener-
ally augments its sedative effect.

Aero-therapeutics. — The application of a rarefied or compressed
atmosphere in bronchial asthma has been of late years gaining ground,
especially on the Continent, where a number of ingenious apparatus
have been contrived for the purpose. In many of these the air is sup-
plied through a mask closely fitting to the nose and mouth, from which
a pipe passes into a hollow cylinder containing a certain volume of air.
This is plunged into a second or larger cylinder containing water. Con-
densation of the air is produced by placing weights on the top of the air
cylinder, and rarefaction by drawing off water from the larger cylinder.
This is the principle of Hauke's, Waldeuburg's, Cube's, and Schnitzler's
apparatus. Some of these machines have two cylinders, one for rarefy-
ing, and another for condensing, which enable the patient to expire into
the rarefied air, while inspiring the condensed air.

These apparatus have the advantage of being portable, and in many
cases a few lessons will enable patients to make a proper use of them,
but they cannot be employed in a severe attack of asthma, where the
sufferer is unequal to the exertion they require, or, indeed, to any exer-
tion. On the other hand, to place the asthmatic in a chamber and
gradually to condense the atmosphere, as is done in the compressed air
bath, is as pleasant as it is advantageous, and entails no exertion of any
kind on the patient's part. Establishments for compressed air baths
exist largely abroad, at Paris, Berlin, St. Petersburg, Stockholm, Brus-
sels, and in many other cities, and in London we have a very good one
at the Brompton Hospital, which is available for private as well as for
hospital patients, and I doubt not, when this treatment is better known, it
will be more largely used. The Brompton apparatus for the compressd
air bath consists of (see illustration): 1, a circular chamber with arched
roof constructed of sheet iron three-sixteenths of an inch thick, strength-
ened by girders and ribs of iron, having a diameter of ten feet, and a
height of eight feet, and capable of containing four persons. The
chamber is fitted with an inlet pipe for the supply of fresh air, and an
outlet pipe for the escape of vitiated air; 2, an eight horse Bteam engine
for compressing the air; 3, and of a central reservoir to receive the air
during compression, and to regulate the current, and to act as a filter-
ing apparatus for purifying and even for cooling it before entering the
circular chamber. This last is fitted with gauges to record the pressure,
with an escape valve, and an airtight cupboard, to enable foods, medi-
cines, or messages to be passed to the inmates of the bath. Each sitting
in a compressed air bath occupies two hours, half an hour being occupied
in raising the pressure gradually to nine or ten pounds (about two-thirdfl

WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA. 135

of an atmosphere), which pressure is maintained at the full for an hour,
and the last half is taken up in reducing it to the normal pressure. The
air rises in temperature during MimpiVUfHl. and falls slightly during

the reduction of pressure, but the general fault of compressed air baths
is that the temperature is usually too high, and in summer this is often
a real difficulty, which has to be met by cooling the air with ice before
it enters the chamber.

136 WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA.

I have submitted a large number of cases of asthma to this treatment,
and almost invariably with great benefit. It appears to lessen the
severity of the attacks, and to lengthen the intervals between them.
The great relief comes from the diminution of the emphysema, as evi-
denced by (1) the reduction of the chest circumference, (2) by the reap-
pearance of hepatic and cardiac dulness, (3) by greater freedom of
respiration. Besides this, cough and spasm subside and there is cessation
of the wheezing and sonorous rhonchus within the chest, the breathing
is easy, but slow, and the pulse is stronger aud tenser than before. It
would appear that the compressed air and warmth, for they seem in-
separable, exercise a sedative influence on the pulmonary plexus and
bronchial muscle, and render them less sensitive to atmospheric and other
changes after leaving the bath. Not only do the attacks become less
tVcijuent, but the respiratory capacity, as measured by the spirometer,
increases, and the general condition is shown by the gain of appetite,
color, and weight, to be improved.

A drawback to this treatment is that to insure any good, permanent
result, a large number of baths must be taken (twenty-four spread over
one or two months is the minimum, and it is often desirable to extend,
the number to fifty or sixty).

I have seen patients carried for the first few times into the air bath,
but soon recovering sufficiently to walk to and from it, and regaining
strength enough for considerable exertion. I have frequently had
recourse to this mode of treatment when all medical and hygienic
methods have failed to reduce the asthmatic spasm, and generally the
result has been most favorable. I cannot agree with some authors who
hold that, this treatment is only useful in asthma combined with catarrh
or bronchitis, as I have found it equally advantageous in pure neurotic
asthma, where the catarrhal element was not present at all, and which
was, in fact, nothing but a pure neurosis.

The casesof asthma in which the compressed air-bath is contraindican-d
are those in which there is distinct valvular disease of the heart, or ex-
tensive cardiac dilatation, but extensive emphysema and bronchitis are
not contraindications, as both affections are largely benefited by its use.
Again, it should be avoided in all cases where there is evidence of either
fatty change in the heart, or atheromatous degeneration of the artcr;

Dietary. — Asthmatics, from necessity, become spare feeders, and are
often very thin. In so many cases a heavy meat meal is followed by an
attack thai a restricted dietary is inevitable. To certain asthmatics
certain articles are specially injurious, while to others they are not so.

1 Km furthi-r information on thU «ubje<t, I inn-it ivIVr tin- nodal t»>iy foetarej on the Compressed
Air kith and ita Uses in the Treatment of Disease (Smith A I

WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA. 137

The dietary which suits most asthmatics best is that which limits them
to two meat meals, vi/.. breakfast and lunch or early dinner, and restr;
their food for the rest of the day to Bqmds, with only bread, toast, or
biscuits ii solids; the great principle being that the asthmatic should
retire to bed with gastric digestion quite complete, and thus preclude
any pressure upward against the diaphragm from flatulent accumula-
tions in the stomach. Where there is much dyspepsia, and especially
where flatulency occurs immediately after meals, it is advisable to omit
r and starch from the dietary and to avoid potatoes, and in these
cases a little alcohol in the form of whiskey, or brandy and water, should
be taken with lunch or dinner. Coffee is generally a suitable beverage,
and should be taken at least once a day, black, as it distinctly lessens
the spasm without rendering the patient sleepless, whereas tea, though it
is a product of the same natural order of plants, acts in a different way
and often increases the neurosis. Various meat extracts, such as Brand's
and Valentine's, and strong beef-tea, especially when taken warm, are
Heat, as they are easily assimilated, and enable the patient to get
over the asthmatic attack without great prostration.

It need hardly be added that all articles of food which are in them-
selves more or less indigestible, such as pastry, pickles, uncooked vege-
tables, salads, garlic, and fruit, except when perfectly ripe, and we may
add cheese in its various forms, and richly dressed or highly flavored
dishes, are to be strictly avoided.

< i.iMATi:. — To many asthmatics climate is everything, and the fact of
their being surrounded by an atmosphere in which they can breathe
freely without fear of spasm means entire abandonment of invalid habits
and a return to active life, usefulness, and happiness. But of all the
perplexing questions of climate, the fitting one for an asthmatic is the
most perplexing, and often involves a series of experiments before success
is achieved

The atmosphere which suits most asthmatics is a dry one, hot or cold,
as the case may be, and a locality rather devoid of trees, or at any rate of
deciduous woods. Open heathery commons with a light sandy or gravel
soil are generally suitable. Fir trees do not seem to affect asthmatics
injuriously, and the combination of sand-soil and fir trees, such as pre-
vails at Bournemouth, is usually beneficial. Soil has a great influence,
and a dry, permeable soil is better than a damp, impermeable one. As
a rule, clay is pernicious; some asthmatics, however, cannot live on
either limestone or chalk, though sandstone and granite are rarely com-
plained of.

Though asthmatic people prefer dry air, they by no means crave for
pure air and generally thrive better in towns, especially in smoky ones,
than in the countrv. This has been an established fact with most asth-

138 WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA.

unities, though from time to time we find exceptions. Still it is so
marked a rule, that it not rarely happens that asthmatics repairing
from the country to see a London physician, lose their asthma the first
night they sleep in London, and finding their enemy gone, return home
without seeing the doctor at all, though unfortunately only to find the
foe awaiting them in their former haunts.

There are many asthmatics, too, who reside in London, and as long as
they do so seldom experience an attack, and are able actually to follow
their vocations with comfort to themselves ; but when they take a holi-
day in the country, and especially if they go in for cover shooting in some
well-timbered and thicketed district, invariably get an attack of asthma,
which makes them hie back to their congenial smoke. I have a patient
now of this kind. He is an active London solicitor, and as long as he
resides in London, or goes to the seaside, he is free from asthma, but if
he accepts an invitation to stay at a frieud's house in the Thames valley,
or takes an autumn shooting in Surrey or Kent, he invariably has an
attack of asthma, which a return to London relieves. Hyde Salter used
to maintain that the more smoky and impure the atmosphere of a large
town is, the better it is for asthma, and really certain of my cases would
appear quite to confirm his conclusion, and the curious feature is that
almost all asthmatics appear to benefit by the London atmosphere, quite
independently of what locality they come from, mountain or valley or
plain, wooded or open, sea or inland. The city generally suits them
better than the West End, and the West End better than the suburbs.
I will give in outline a very striking case.

A gentleman, aged fifty-five, was sent to me by Mr. Mules, of Idmin-
ster, in October, 1873. He had suffered from phthisis, which had been
arrested by a sojourn in Madeira in 1855. He had considerable consoli-
dation and fibrosis of the right lung, and he was also liable to attacks of
gout. He resided in a damp valley in Somersetshire, and for the last
three months had suffered from severe paroxysmal dyspmva coming on
nearly every night, and subsiding by day, accompanied by oedema of the
ankles. The urine was scanty, sp. gr. 1034 and contained albumin.
There was marked dulness over the lower two-thirds of the right lung
with bronchophony. Prolonged expiration and wheezing sounds were
heard over the left Inn- There was no displacement of the heart; the
respiration was slow, with very prolonged expiration.

After being ten days in London, and taking only a little alterative
medicine, the dyspnoea disappeared, the oedema subsided, and the albumin
vanished from the urine. Finding himself so well, he remained in Lon-
don daring November and December, walking out in the fogs, which
happened to he more frequent and dense than usual, without harm or
inconvenience. In January, 1874, he tried Dover tor a few days, hut had

to return to London on account of the asthma, and staying here con-
tinned well, with the exception of occasional gouty attacks, until March,
when he returned to Somersetshire. He was free from asthma until
dune, and then, with the increase and luxuriance of the vegetation, the

WILLIAMS, TREATMENT OF BRONCHIAL ASTHMA. 139

asthma returned, and obliged him again to take refuge in London.
During this summer visit he did not at first gain complete freedom from
thf spasm as h<- lia<l done in winter, owing perhaps to the air being freer

D smoke, and I had recourse to various climatic experiments to assist
him. First, I sent him on trips on the river to Gravesend and back, with
no advantage. He tried the theatre, and in the hot, stifling, gas-smell-
ing gallery he lost his spasm for the time. I then recommended the

ropolitan Railway, where he breathed freely, and was especially com-
fortable in the part between Baker Street and King's Cross, which is gen-
erally credited with being the most impure and worst ventilated section of
the whole line. lie travelled up and down the Metropolitan line several
times a day for a week, and then was able to return to Somersetshire,
but only to get it again soon after, with renewed dyspnoea and with

:ua of the legs this time; for Weymouth, where he was no better,
and by my advice, as London was inconvenient for him, he tried Bristol,
but first stopping in the outskirts of the city, was no better; but when
he took up his quarters near Guildhall, in the heart of the smoky city,
he scon got relief. However, in spite of all these lessons, he once more
returned to his Somersetshire home, where his troubles soon accumu-
lated ; the oedema of the legs increased, and ascites appeared with oedema
of the abdominal walls. Albumin and casts were abundant in the urine,
and it was clear that he was becoming water-logged. In this desperate
condition he had himself conveyed to London to be under my care, but
though tapping the abdomen, and puncturing the legs, gave temporary
relief, he sank, and died exhausted May 25, 1875.

Though this case was primarily one of phthisis and gout, the asthma
was the chief and most troublesome feature, and the remarkable influ-
ence the London atmosphere exercised over this, even when pulmonary
and vascular destruction had given rise to oedema and albuminuria, was
a etrikiiig instance of the climatic treatment of disease.

The chief points in which the London and other smoky town atmos-
pheres differ from those of the open heath, of the seashore, or of the
mountains of Scotland, are, according to the late Dr. Angus Smith, that
(1) they are more dry, '2) they contain more carbonic acid (it may be
added, free carbon), and (3) they have less oxygen. It is possible, how-
ever, that the various emanations from the escape of coal and other gases
may add to the sedative effect on the asthmatic spasm.

All cases of bronchial asthma are not so favorably affected by the
smoky atmosphere, and some patients require dry, pure air, and often
warm air — I know several instances. For some, Bournemouth is very
well suited, or, if more warmth be required, one of the warm, dry, non-
stimulating climates is desirable, such as Hyeres, near Tolon ; Cimiez,
near Nice ; and Teneriffe. The climate of Hyeres acts more favorably
on asthma than any other I know, and its qualities appear to be due to
its great warmth, dryness, and distance from the Mediterranean. I have
seen dozens of asthmatics lose their attacks in this fine climate. The
Riviera generally is far too stimulating, but I have known asthmatics
pass winters on the Nile, breathing the desert air with great benefit.

TOL. 97. KO. 2.— XVQV8T. 1888. 10

140 HUN, PRUDDEN, MYXEDEMA.

Lately the high altitudes have been tried for asthma, and cases of pure
bronchial asthma, without emphysema, have done exceedingly well at
St. Moritz and Davos. One patient of mine went to Colorado and lost
his asthma, and also his fortune in mining speculations at the base of
Pike's Peak. Here it must be the great dryness and freedom from dense
vegetation, and the open-air life, which give immunity from attacks.

MYXCEDEMA.

FOUR CASES, WITH TWO AUTOPSIES.

By Henry Hun, M.D.,

PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM AND OF PSYCHOLOGICAL MEDICINE IN THB
ALBANY MEDICAL COLLEGE.

WITH A REPORT OF THE MICROSCOPICAL EXAMINATION.

By T. Mitchell Prudden, M.D.,

DIBECTOR OF THB LABORATOBY OF THE ALUMNI ASSOCIATION OF THB COLLEGE OF PHYSICIANS AND SUB'.!

NEW YOBK.

SECOND PAPER.

The four cases of myxoedema which have been described at length
in the first paper1 resembled each other very closely. In order to learn
in what respects they resemble and in what respects they differ from
other cases already published, I have examined the literature of lli>'
subject, and, after excluding all cases occurring in idiots, and those
due to extirpation of the thyroid gland, and several of doubtful diag-
nosis, I have tabulated 150 cases of myxoedema which have been more
or less completely reported, and propose briefly to compare the four
cases which I have reported with these 150 tabulated cases. .

Sex. 2 of the 4 cases are males, and 2 females. Of the tabulated cases
32 are males and 113 females, while the sex is not stated in 5. Females
then exceed males in the proportion of about 3£ to l.1

Age. In the two women, the disease commenced at the age of
forty-nine years; in one of the men at eighteen, and in the other at
thirty-three years. Of the tabulated cases, the age at which the di-
commenced is stated in the cases of 76 women, and of 20 men ; the
earliest age at which the disease commenced was in a child eighteen
months old, as the result of an injury to the head and neck; and the
latest age was in a woman sixty -seven years old. The disease commenced

' See the July number of this Journal.

* In this, as in all subsequent Instances, the deductions are drawn from the 150 tabulated cases,
i bcnsjd ■ ith the 4 case* which I have reported.

HUN, PRUDDEN, MYXEDEMA. 141

at about the same age in the ease of married and of unmarried women.
The average age at which the disease commenced in the 76 women was
thirty-eight years, and in the 20 men forty-two years. The following
table shows the age at which the disease commenced in these 96 cases,
arranged in decenniums.

1 to 10 years . .

. . 1

40 to 50 years . .

. . 26

!•» to 20 " . .

. . 3

50 to 60 " . .

. . 17

20 to 30 "

. . 16

60 to 70 "

. . 2

30 to 40 " . .

. . 31

70 to 80 " . .

. . 0

In the cases of 30 women and 10 men the date of the commencement
of the disease is not given. The following table shows the ages of these
4( i cases at the time the observation was made, the oldest case being that
of a woman seventy-six years old.

1 to 10 years . .

. . 0

40 to 50 years . .

. . 15

10 to 20 " " . .

. . 1

50 to 60* " . .

. . 10

Wto80 " . .

. . 1

60 to 70 " . .

. . 4

30 to 40 " . .

. . 8

70 to 80 " . .

. . 1

This table corresponds very well with the first one when we consider
the long duration of a case of myxoedema.

It is evident that the disease may commence at any age from infancy
to old age, but most commonly commences between the ages of thirty
and forty years (the tabulation shows that it commences with the greatest
frequency between the ages of thirty-five and forty years).

Heredity. In the case of the 2 males the disease appeared to be present
in a mild form in their brothers or sisters; in Case I. the daughter
showed signs of the disease, and in Case II. there is a strong neurotic his-
tory in the present generation. In the tabulated cases there are three
sisters from one family, two sisters from another family, and another
woman had a sister (case not reported) who had the disease ; thus six cases
or three families had sisters who had the same disease. Another case
had both a father and a sister who had it ; two other cases had mothers
who had the disease, and one case (one of the three sisters mentioned
above) had a daughter in whom the disease was apparently commencing.
Of the tubulated cases some mention is made of the family history in 53 ;
in 25 the family history is noted as being good ; in the family history of
4 there was dropsy ; of 2 there was rheumatism ; of 4 there was cancer ;
of 9 there was tuberculosis; of 13 there were nervous diseases, and in
these latter families insanity occurred 5 times.

In a few cases (8 per cent.), then, there seems to have been a direct
inheritance of the disease, and in about an equal number of cases the
disease occured among brothers and sisters. The number of tuberculous
family histories (17 per cent.) is rather excessive, and the number of
cases in which there is a neurotic family history (25 per cent.) is

142 HUN, PRUDDEN, MYXffiDEMA.

decidedly excessive, and when we consider the numerous symptoms of
nervous derangement occurring in myxoedema we are the more inclined
to attach significance to a neurotic family history.

Etiology. The two women were both married ; each had given birth
to five children, and in each the disease commenced at the time of the
menopause. In Case III. there is a history of syphilis and of excessive
drinking and smoking ; while in Case IV. there is nothing which can
serve as an etiological factor. In the tabulated cases, 82 of the women
were married, and 14 were single, while in 17 there is no mention made
of this point. A statement is made in regard to the number of children
of 64 of the 82 married women, the results of which are that 4 had no
children, 6 had 1 child, 6 had 2 children, and one of these 6 had 1
miscarriage; 3 had several children, 10 had 3, and 1 of these 10 had
also 1 miscarriage ; 3 had 4, 3 had 5, 6 had 6, and of these 6 1 had had
2, and 1 had had 4 miscarriages ; 10 had 6, and 2 of these 10 had also
1 miscarriage each ; 7 had 8, and 2 of these 7 had also 2 miscarriages
each, and 1 had 5 miscarriages; 2 had 9, and 1 of these 2 had several
miscarriages; 2 had 11, 1 had 14 children and 7 miscarriages, and 1
had an excessive number of children. Thus 64 women had more than
300 children and 29 miscarriages. In only 3 of the tabulated cases is it
definitely stated that the disease commenced at the menopause, although
in a number of other cases it occurred about that time. Of the tabulated
cases there is a history of anxiety or mental shock in 27, of menorrhagia
or excessive hemorrhage in 13, of severe injury in 8 (5 of these being
injuries to the head), of syphilis in 3, of intermittent fever in 4, of tetany
or functional spasm in 2 ; and it is stated that the disease commenced
during or immediately after pregnancy in 15 cases, immediately after
an excessive hemorrhage in 6 cases, immediately after an injury in 5
cases, and immediately after a mental shock in 10 cases.

Thus the most important etiological factors would seem to be excessive
childbearing, excessive hemorrhage (it is evident that these two factors
may be related), mental shock and worry, and injuries, especially in-
juries to the head. It is to be remembered, however, that hemorrhages
are a common symptom in myxoedema, and it may be that the hemor-
rhage! mentioned as an etiological factor were an early symptom of the
disease itself, and that in a certain number of cases the worry which the
patient assigned as an etiological factor may have been due to the mental
impairment which often manifests itself later in the course of the disease ;
for among the cases in which worry is assigned as a possible cause, in
only two in the fully developed disease is the intelligence said to be good.

Omet. In the four cases the disease commenced insidiously by a
gradual and steadily increasing swelling of the skin; in Case III.
alone, the patient first complained of eczema. Uf the tabulated cases,
10 commenced with neuralgic pains; 5 with an attack of insanity;

HL'N, PRUDDEN, MYXCEDEMA. 14.3

3 with erysipelas ; 2 with convulsions ; 2 with exophthalmic goitre ;
2 with eczema ; ami 1 each with tetany, dropsy, and gastric fever.
Where tin disease did not commence insidiously, then, it usually
commenced with some disease of the nervous or cutaneous system.

Face. In all the four cases there was a very peculiar and characteristic
appearance of the face. The complexion was waxy, with a patch of livid
.restion on each cheek, the skin was swollen, the eyelids wrinkled,
jy, and translucent, the lips everted, the nose broadened, and the
nasolabial fold accentuated, especially as it runs up on the nose. In all
of the tabulated cases, whenever the appearance of the face is described
in detail, this same description of it is given ; so that this facial appear-
and int and characteristic feature of the disease.

timeout membranes. In all the four cases not only was the skin of the
face swollen and waxy, but the mucous membrane of the mouth was also
len and anaemic, and the same condition was found to be present in
the larynx in the three cases in which a laryngoscopic examination was
made. Either in consequence of this infiltration of the mucous mem-
branes and probably of the muscles also, or in consequence of a paresis
of the laryngeal muscles, the vocal cords were not normally approxi-
mated in phonation in any of these three cases. Of the tabulated cases,
the mucous membrane of the mouth was swollen in 26, swollen and
anaemic in 25, normal in 5, the gums hypertrophied and vascular in 3,
and in 91 cases the condition was not noted. The condition of the
larynx is noted as having been anaemic in 2 cases, doubtfully swollen in
1 case, and normal in 1 case ; and in 1 of these cases the vocal cords did
not approximate closely in phonation. The mucous membrane of the
mouth was then swollen in 95 per cent., and anaemic in 47 per cent, of
all the cases in which its condition was noted. The mucous membrane
of the larynx was anaemic in 70 per cent., swollen in 56 per cent., and
the vocal cords did not approximate closely in 56 per cent, of all the
cases in which a laryngoscopic examination was made.

/. In connection with the laryngoscopic examination, it may be
stated that in each of the four cases an ophthalmoscopic examination
was made and that in the two women there was a slight atrophy of the
optic nerve, and the retina was hazy as if it were oedematous or
infiltrated with some substance, while in the other 2 cases the fundus
normal. Of the tabulated cases, an ophthalmoscopic examination
was made in 22. The fundus was found to be normal in 16, there was
an increase of fibrous tissue in 2, an atrophy of the nerve in 2, a neuro-
retinitis in 1. and a hazy condition of the retina in 1.

The fundus was, then, normal in about 70 per cent, of the observed
cases, there was an atrophy of the nerve in 16 per cent., a hazy condi-
tion of the retina in 12 per cent., and an inflammatory condition of the
nerve and retina in 4 per cent.

144 HUN, PRUDDEN, MYXEDEMA.

Skin. In all the four cases the skin Was thickened, dry, rough, and
scaly ; and in places, especially on the hands, was loose and baggy as if
the hands were covered with badly fitting parchment gloves. The
thickening of the skin was more marked on the face, hands, and body,
than on the legs, and it either did not pit at all or pitted only very
slightly upon long-continued and strong pressure. It was of a yellow
tinge, and the two women presented patches of chloasma and pigment.
Of the tabulated cases the skin is noted as having been thickened or
swollen in 26 ; in addition to its being thickened, it is noted as dry and
rough in 54 ; to all these qualities the term scaly is added in 39 ; and
the skin is called thickened, dry, and wrinkled in 8 ; in only 1 case is
the skin noted as having been moist rather than dry, and in 25 cases the
condition of the skin is not noted. In every instance, then, the skin is
noted as having been thickened ; it is noted as thickened, dry, and rough,
or wrinkled in about 50 per cent, and scaly in about 30 per cent, of
the cases. It is probable that had the condition been more carefully
described, it would have been found dry, rough, and scaly more often
than the figures given above indicate, and that the condition of the
skin would have been found to be as characteristic of the disease as is
the appearance of the face. In 12 cases the existence of moles was
noted, in 13 cases the skin had a yellow tinge, and in 5 cases there were
patches of chloasma or pigment.

Hair, nails, and teeth. In all the four cases the hair had fallen out
more or less completely from all the parts where it normally grows, and
in Case I., after it had fallen out, it grew in again. In 3 of the
cases the nails were badly formed, and in 2 they were brittle. The
teeth were brittle and broke easily in Case I., and they were loose and
fell out in Case IV. Of the tabulated cases, the hair is noted as normal
in 7, as having fallen out more or less completely in 63, as having fallen
out and grown in again in 34, as having shown an increased growth
and abnormal appearance in 4, as having been soft in 2, as dull and dry
in 8, and the condition of the hair is not noted in 70 cases. The con-
dition of the nails is noted as normal in 3, and as malformed and brittle
in 10 cases. The teeth were noted as normal in 4 cases, as having fallen
out in 24, as brittle in 4, as loose in 15, as decayed in 13, and their
condition was not noted in 92 cases. It may be said, then, that not
only were the skin and mucous membranes changed in character but the
epithelial appendages were greatly altered, the hair had fallen out in
about 86 per cent, of all the cases in which its condition was noted, and
was altered in character in other cases. The nails were malformed and
brittle in about 75 per cent, of all the cases in which their condition
was noted, and the teeth were noted as being loose or having fallen out
in about 64 per cent., and as being decayed or brittle in about 28 prr
cent, of all the cases in which their condition was noted.

HUN, PRUDDEN, M Y X<K UK M A. 145

Persjii ration ami oth>r >.rcr<ti<»u<. In all four cases there was either
ii" perspiration at all or it was very slight. The secretion of tears,
saliva, ami mucus from nose was unaffected in Case III., but in each of
t lit* other three cases these secretions were profoundly affected: thus in
II. they were absent or very scanty till toward the end of life,
when there was often a free watery discharge from the nose; in Case I.
the nasal discharge was increased ; and in Case IV. all these secretions
wete greatly increased and varied on the two sides of the body; it was
only neoenary tor him t<> bend his head forward at any time to cause
a watery discharge to drop slowly from his nose. In the tabulated

s, perspiration is noted as being absent or greatly diminished in 36,
and as being increased in 3, in the other cases it is not noted. In 18

- there is noted an increased and in 1 a diminished discharge of
saliva ; in 11 cases an increased discharge from eyes and nose, and in 2

I polyuria is noted. It seems, therefore, that the perspiration was
almost constantly diminished or absent, while the saliva and the dis-
charge from the nose and eyes was almost as constantly increased.

Temperature. Subjectively all the four cases felt chilly, and they all
felt worse in cold weather, although in Case IV. the swelling was greatest
in hot weather. Case I. complained at times of flushing and burning

itinns, and these sensations were very prominent symptoms in the
two sisters of Case IV. Objectively, the skin of Cases I. and II. felt
cold to the touch, and in Cases II. and IV., with the thermometer, a
subnormal temperature was found not only in the axillae, but also in
I V. in the mouth and rectum, and the temperature of his left axilla
\\:i> lower than that of his right. Of the tabulated cases, 45 complained
of an almost constant feeling of chilliness, although flushing of face and
flashes of heat, especially in the early stages, were prominent symptoms
in 4. In 14 cases it is stated that the patient felt worse in cold weather.
The temperature was found to be normal in 8, and subnormal in 69

-. In 9 cases there was a difference between the temperature of the
two axillae, the left being the lower more often than the right. In one
case, shortly before death, the temperature fell to 66° F., the pulse being
20 and the respiration 12. The temperature, then, was found to be sub-
normal in nearly 90 per cent, of the cases in which a thermometer was
employed. This subnormal temperature readily explains the chilly sensa-
tions of which so many patients complain, and it is possible that the
flu>hings and burning sensations noticed in some cases, especially in the
early stages, are due to the fact that the skin cannot get relief through
perspiration. In the case of the two sisters of Case IV., who complained
especially of flushing and burning sensations, there was little or no per-
spiration.

I'u[.*e. In 2 of the 4 cases the pulse was below 70, in 1 it was 73,
and in the other case the pulse rate was not noted. In 3 of the cases

146 HUN, PRUDDEN, MYXCEDEMA.

the sphygmographic pulse curve showed high tension, while in one it
showed low tension. Of the tabulated cases the pulse rate was below
70 in 33, and above 70 in 23. In 12 it was small, in 7 weak, in 2 full
and strong ; in 4 there was diminished tension, and in 2 increased ten-
sion. In the majority of cases, then, the pulse was slow and small, or
weak.

Respiration. The respiration was not noted in any of the 4 cases. In
the tabulated cases the respiration was noted 9 times. In 2 it was said
to be interrupted ; that is, there was a pause after the inspiration as
long as the inspiration itself; in 4 the respirations were 18 per minute,
in 1 case 16, and in 3 cases 14 or less.

Cerebral junctions. In all 4 cases the memory was poor, and the
mental condition dull and confused ; in three cases there was insomnia ;
in one there was well-marked insanity, with hallucinations and delu-
sions, and in two cases vertigo was a prominent symptom. Of the tabu-
lated cases the mental condition was noted in 102. It was noted as
normal in 9, as dull or sluggish in 66 ; failure of memory was noted in

34, insanity or hallucinations in 20, mental enfeeblement in 13, irrita-
bility in 9, vivid dreams and nightmares in 5, insomnia in 2, and vertigo
was a prominent symptom in 9. The cerebral functions were, then,
decidedly affected in most cases. In more than half the cases the mind
was dull and sluggish, failure of memory occurred in one-third and
insanity in one-fifth of the cases.

Special sensibility. In all four cases vision was more or less impaired,
and there was a concentric limitation of the field of vision which was
most extreme in Case II., and was slight in Cases I. and IV. The other
special senses were normal, although Case I. complained of deafness, but
this could not be detected on examination. Of the tabulated cases, the
patients stated that their sight was impaired in 24, and normal in 27,
and in 2 of the 24 cases a careful testing of the vision showed a decided
impairment of vision. The patients stated that their hearing was normal
in 25, and impaired in 28 cases. Taste and smell are noted as having
been normal in 31, and impaired in 11 cases. Thus, in about half of
all the reported cases the hearing and sight were impaired ; while the
taste and smell were impaired in about one-third of the cases. It is to be
remembered, that the statements of the dull and stupid patients suffer-
ing from myxedema are not altogether reliable, and that they state that
their sensibility is impaired, when an accurate examination might not
always reveal any impairment, as in Case I. ; so that these figures are
probably too high.

Cutaneous sensibility. In all four cases the cutaneous sensibility was
normal. Neuralgic pains were present in the course of the disease in
Case II. Of the tabulated cases the cutaneous sensibility was normal in

35, diminished in 21, retarded in 10, there was hyperesthesia in 4. and

HUN, PRUDDEN, MYXCEDEMA. 147

the patients complained of numbness in 14 cases. In addition to the 10
cases in which the disease commenced with neuralgic pains, such pains
occurred Soring the course of the disease in one other case. The impair-
ment of sensibility was probably rated too high, for the same reason as
was given concerning the special senses, but a diminution of sensibility
was certainly present in a considerable number of cases.

Reflexes. In all four cases the superficial and deep reflexes were normal.
Of the tabulated cases the superficial reflexes were normal in 6, dimin-
ished in 6, tardy in 2, and absent in 3. The deep reflexes were normal
in 14, exaggerated in 2, diminished in 6, tardy in 3, absent in 5 ; while
of 2 other cases the superficial reflexes were exaggerated and the deep
reflexes absent in the one, and the deep reflexes were exaggerated and
the superficial absent in the other. The reflex actions were abnormal,
then, in more than half the cases, being most commonly diminished or
absent, often tardy, and rarely exaggerated.

Motility. In all four cases all movements were executed slowly and
feebly, the walk was unsteady, and they often fell. Of the tabulated
cases, the condition of motility is noted in 147 ; the movements were slow
in 13, weak in 21, slow and weak in 75, in 36 the word awkward is
added, and in 19 it is stated that the patient falls, or is greatly afraid of
falling. In no case is the motility noted as normal. Therefore the
movements were executed slowly or feebly, or both, in all reported cases,
and awkwardly in 24 per cent.

Speech. In all four cases the speech was slow and hoarse. Of the tabu-
lated cases the character of the speech is noted in 107, it was normal in
3, slow in 100, hoarse in 41, nasal in 21, monotonous in 17, and thick
and indistinct in 20. The speech was, therefore, slow in almost every
case reported, was hoarse in over 40 per cent., and was changed in other
respects in many other cases.

trioal excitability of the muscles. In all four cases an electrical exami-
nation of the facial muscles with both the faradic and galvanic current,
showed no alteration in the quality, but a decided quantitative diminu-
tion in the electrical excitability of these muscles. Of the tabulated
s, the electrical excitability was noted in 13, in 4 it was normal, in 3
it is merely stated that the muscles responded to one or both kinds of
electricity, in 5 there was only a feeble response to strong currents, and
in one case which came on during tetany, as the myxoedema developed
the electrical excitability, which had been exaggerated, became dimin-
ished and AnOC=KaCC. It may be fairly doubted whether accurate
measurements were made in some of these cases in which an electrical
examination was made, but the electrical excitability of the muscles was
diminished in at least 60 per cent, of the cases.

Thyroid gland. In none of the four cases could the thyroid gland be
felt. It is very doubtful, however, if a normal thyroid gland could be

148 HUN, PRUDDEN, MYXEDEMA.

felt in such fat necks as those of these patients. There was no abnormal
mobility nor compressibility of the trachea in the two cases in which
this sign was noted. Of the tabulated cases, the condition of the thyroid
gland was not noted in 82, it could not be felt in 38, it was diminished
in size in 11, it was normal in 14, it was enlarged in 2, in 1 of which
there was double exophthalmos, and it had been enlarged, although not
to be felt at the time of the examination, in 3. In 2 cases the trachea
was more movable and compressible than normal. The thyroid gland
appears to have been diminished, then, in 78 per cent, of all cases.

Supraclavicular fat. In all four cases there were prominent masses
of fat in the supraclavicular fossae which atrophied somewhat before
death in the two fatal cases. Of the tabulated cases, the existence of
this pouch is noted as being present in 24, and as being absent in 3.
In the other cases no statement is made regarding it. From which it
would appear to have been present in 90 per cent, of all the cases in
which its condition was noted.

Thoracic and abdominal viscera. In all four cases a careful thoracic
and abdominal examination revealed only healthy conditions, except
that in one case there was ascites, and in all cases there was an enlarged
pendulous abdomen. Of the tabulated cases, the abdomen is noted as
being enlarged or pendulous in 11, in 4 there was ascites, in 17 the
heart's action was weak, in 3 there was cardiac hypertrophy, in 4 there
was reduplication of the heart sounds, in 10 there was accentuation of
the aortic second sound, in 1 there was valvular disease, in 5 there were
cardiac murmurs, probably anaemic, and in 4 the arteries were hard and
resistant. In 61 cases the abdominal and thoracic viscera were noted
as being normal. In a considerable number of cases, then, there was a
pendulous abdomen, and in a still larger number of cases the heart
presented some abnormality.

Urine. In two of the four cases the urine was free from albumin.
In Case I. there was no albumin at first, but subsequently albumin and
casts were found in the urine, and albumin, casts, and blood were found
in the urine of Case IV. Sugar was not found in any of the eases. < >f
the tabulated cases, the condition of the urine is noted in 113, in 33 the
specific gravity of the urine was 1015 or less, and in 30 above 1015 ;
in 27 the amount of urea excreted was greatly diminished, and in
1 normal; albumin was absent in 91, and present in 21 cases; in 8
of these 21 the albumin did not appear in the urine until late in the
course of the disease, and in 5 of these 21 the albumin was not constantly
present, but appeared from time to time. Casts were present in the
urine in 4 cases, and blood in 1. In 1 case there was sugar in the urine
and polyuria during a short period of time. It appears, then, that in
the majority of cases the specific gravity of the urine was low, and that

HUN, PRUDDEN, MYXCEDEMA. 149

the amount of urea secreted was usually diminished, and that albumin
w;i- present in the urine in about 20 per cent, of all cases.

Blood. In all four cases an examination was made of the blood.
There was no increase in the number of white corpuscles, and the red
corpuscles were of normal appearance, and in slightly diminished
number, varying from 3,004,000 to 4,091,000 in the cubic millimetre
(normal blood containing from 4 to 5 millions red corpuscles in the cubic
millimetre). Of the tabulated cases, the blood was examined in 17. In
7 the blood appeared normal, in 4 there was a deficiency of red corpus-
cles, in 4 there was an increase in the number of white corpuscles, and
in 2 there were both a deficiency of red corpuscles and an increase in
the number of white corpuscles. The blood, then, showed a deficiency of
red, or an excess of white corpuscles, in about 70 per cent, of all cases.

Hemorrhages. There is no history of hemorrhages in any of the four
cases, except in Case IV., who frequently suffered from severe hemor-
rhage from his nose, gums, and bladder. Of the tabulated cases, the
subject of hemorrhage is noted in 42. In 1 of these it is stated that
there was no hemorrhage of any kind, in 3 there was araenorrhoea, in 19
there was menorrhagia, in 5 there was an excessive loss of blood during
or after labors, in 8 there was very excessive hemorrhage after the
extraction of teeth, in 4 the gums bled easily, in 6 the patients said that
they bled very easily, and that a slight pin-prick caused either an abun-
dant hemorrhage, or an extensive ecchymosis, in 3 there was bloody
urine, in 2 there was frequent and severe epistaxis, in 2 there was
hemoptysis ; in 1 there was purpura, and in 1 the disease commenced
r a great loss of blood during an operation. Hemorrhage, then,
occurred in a great variety of ways in about 83 per cent, of all the cases
in which the symptoms were noted, and must, therefore, be regarded as a
very prominent symptom of myxoedema.

nwsis and course of the disease. In all four cases the symptoms
presented considerable variations during the course of the disease ; the
swelling of the skin and the other symptoms being much worse at
certain times than at others. In all the cases the duration of the disease
WM measured by years; Case IV. having lasted ten years. Two of the
cases died in coma. Case IV. thinks that he is improving, but the
improvement, if any, is very slight. Case III. has made decided
improvement, especially in strength and mental clearness, but his
appearance continues characteristic, and he is far from well. The sister
of Case IV. claims to have made a complete recovery, but as she was
not seen when the disease was at its height her claim to be considered
as a case of myxoedema which has recovered is somewhat doubtful. Of
the tabulated cases, only 2 ended in complete recovery, but inasmuch
as one of these cases ran its entire course in seven months, and exhibited
an unusual degree of paralysis, and the other case is the solitary one in

150 HUN, PRUDDEN, MYXCEDEMA.

which the skin was rather moist than dry, and as this case is not
described in much detail the diagnosis of these two cases is not entirely
above suspicion. In the second of these two cases recovery was
attended with profuse perspirations. Certainly, if recovery does take
place, such a termination of the disease is extremely rare. Some of the
other cases improved somewhat under various forms of treatment, but
in no other case did the improvement go on to recovery. The disease
usually lasts a number of years, and in a few cases lasted between fifteen
and twenty years. The manner of death is noted in 12 of the 150 tabu-
lated cases : 6 died in coma, 4 died of pneumonia or other pulmonary
disease, 1 of pericarditis, and 1 of exhaustion.

Treatment. In regard to treatment there is little to be said. Nitro-
glycerin seemed to produce a happy effect at first in Case II., especially
on the temperature, but it produced no permanent improvement in this
or in the other cases ; and, indeed, none of the few medicines that were
tried produced any decided effect, except that jaborandi produced no
diaphoresis in Case IV., but, perhaps in consequence of its failure to
produce diaphoresis, caused a very alarming condition of prostration.
The sister of Case IV. claims that she recovered completely under the
almost daily use of baths and friction. In the tabulated cases the treat-
ment is not dwelt upon at any great length. Strychnia was given with
good effect in 3, and without good effect in 3 cases. Tonics were given
with benefit in 2, and without benefit in 7 cases. Digitalis and iron
apparently caused improvement in 1 case. Electricity produced a
good effect in 1, and was without good effect in 1 case. Baths were
given with good effect in 1, and were without good effect in 3 cases.
Jaborandi apparently did good in 1, but was of no value in 5 cases.
Nitro-glycerin seemed to produce an excellent effect in 1, but this case
subsequently relapsed and was worse than it had been before, and the
same drug was given in 3 other cases without benefit. Arsenic, milk
diet, friction and hot-air baths were beneficial in 1 case each, and 3 cases
exhibited an improvement which could not be attributed to any special
method of treatment.

Pathological anatomy. If we turn from the consideration of the
clinical aspects of the disease to that of its pathological anatomy, wo
have as a basis tor such a consideration the post-mortem examination of
two of the four CMOt, and Dr. Prudden's most important ami complete
reports of the microscopical examination of the organs in these two
cases. The most marked lesions found (and they are almost identical
in the two cases) were :

1st. A MparatioD of the fibres of the superficial layers of the corium,
as if the skin had been infiltrated with some fluid or semi-fluid substance,
which, in the first case, certainly, was shown not to have been mucin.

HUN, PRUDDEN, MYXCEDEMA. 151

Alon-r with this change in the skin, there was, in the second case, a
simple atrophy of the hair follicles.

2d. Almost complete destruction of the thyroid gland, which is shown
not only by its small size, but also by an excessive atrophy of the
parenchyma and a greatly increased amount of connective tissue. Very
remarkable is the new formation of lymphatic tissue in the thyroid.

3d. Arterial lesions. The arteries throughout the body were the seat
of obliterating endarteritis, with more or less atheromatous degenera-
tion, and in places the arteries presented amyloid degeneration. Collec-
tions of small spheroidal cells were grouped about the smaller blood-
vessels in many localities, and hemorrhages and hemorrhagic infarctions
bore witness to the arterial degeneration.

4th. Hypertrophy of the left ventricle.

5th. Chronic diffuse neuritis.

6th. Interstitial hepatitis.

7th. Fat is atrophic, and this atrophy is most marked where "the fat
has a gelatinous appearance, as was the case with the subpericardial
fat in Case II.

8th. Fatty degeneration of the suprarenal capsules.

In both cases there was an increase in the subarachnoid fluid, and in
one case an effusion into the serous cavities generally. In Case I. there
were cerebellar hemorrhages and hemorrhagic infarctions in the mucous
membrane of the stomach. In both cases there were pleuritic adhesions.
In neither case was anything abnormal found in the sympathetic or
cerebro-spinal nervous system.

Of the tabulated cases there is a more or less complete report of an
autopsy in 17. In none of these is there any special description of the
skin except that cutaneous oedema was noted in 2 and purpura in 2, but
in 4 cases of myxoedema portions of the skin were excised during life
and examined, with the result that there was a widening of the lymph
spaces and crowding apart of the tissues in 3, a thickening of the
vessel walls in 2, an increase in fibrous tissue in 1, and in 1 the connective
tissue was indistinct and seemed to be made up of gelatinous fibres.

The condition of the thyroid gland was noted in 8 cases. It was atro-
phied in 6, and was so injured in making the autopsy in 1 that its size
could not be determined, in 1 it was the seat of a cancerous growth
which had apparently commenced subsequently to the development of the
myxoedema, in 1 case there was " cell proliferation," and in 1 case new
growth of connective tissue in the thyroid. Dr. Hadden1 stated, at a
meeting of the London Medical Society in 1885, " that he had exam-
ined the thyroid gland in six or seven cases of myxoedema. Outside the
acini there was a round-celled infiltration which became organized into

> Lancet, 1885, rol. i. p. 709.

152 HUN, PRUDDEN, MYXCEDEMA.

fibrous tissue ; the cells of the acini underwent proliferation and became
fibrous in structure."

Thickened arteries were noted in 8 cases, and in 1 case it was noted
that there was thickening of the adventitia of the arteries and almost
complete obliteration of their calibre. Hemorrhage is noted in 2 cases
(both cerebral).

Hypertrophy of the left ventricle was noted in 6, dilatation in 1, and
the heart was said to be normal in 2 cases.

The condition of the kidney was noted in 14 cases, it exhibited the
lesions of chronic diffuse nephritis in 12, it was cystic in l,the adventitia
of the arteries was increased in 1, and the kidney was normal in 2
cases.

The liver was the seat of interstitial hepatitis in 5 cases, and was
normal in 2.

The fat of the body was yellow and moist in 2 cases.

The "suprarenal capsules were atrophied in 1 case and normal in 1
case.

In 5 cases there were ascites and effusion into the pleural cavity,
and in 6 cases effusion into the pericardium. In 2 cases there were
general pleuritic and peritoneal adhesions. There was an increase in
the subarachnoid fluid in 1 case.

The brain was normal in 2 cases, there was cortical atrophy in 2, and
cerebral hemorrhage (mentioned above) in 2. The spinal cord was
normal in 1 case, and the anterior horns were degenerated in 1 case.
The peripheral nerves were examined in 1 case and found to be normal.
The sympathetic ganglia were hypertrophied in 1 case, normal in 1,
and in 1 the interstitial tissue was increased in amount without there
being any new growth of it.

The pituitary body was normal in 2 cases, and hypertrophied in 1.
The mucous membrane of the larynx was swollen in 3 cases. The sub-
maxillary gland was normal in 1 case, and in 1 case the interstitial tissue
was increased in amount without there being any new growth of it.

The connective tissue generally throughout the body presented a
" sodden " appearance in 1 case, and was swollen and translucent in 2
cases.

The description of most of the autopsies is fragmentary, at least in
the form in which I have found them reported, and leaves much to be
desired ; but as far as they go the results of the autopsies confirm the
deductions which have been drawn from Dr. Prudden's report, and. in
addition to these, they show that the mucous membrane of the larynx
is usually swollen, that the cortex of the brain is sometimes atrophied,
and that there is an alteration in the connective tissue throughout the
body. The changes in the other organs are found so rarely that they
may well be accidental.

HUN, PRUDDEN, MYXEDEMA. 153

* 'tuition. In Case I. the skin was examined for mucin,
ami no more mucin was found in this skin than was found in an equal
quantity of skin of a fairly well-nourished woman, which was taken as
■ control experiment. Among the tabulated cases, an examination for
mucin was made in three cases. In one no excess of mucin was found,
in another fifty times as much mucin was found in the skin as was found
in an equal quantity of oodeantoni skin, and in the third case the mucin
in the skin was found increased, being 0.08 per cent., although I can
find no account of any control experiment having been made.

It appears, then, that the amount of mucin in the skin is not so
invariably increased as has been supposed, or as would justify the
name myxoedema, and that the peculiar nature of the oedema in these
cases does not depend, in many cases at least, upon an infiltration of the
skin with mucin. A possible explanation of the fact that in myxoedema
the skin, although cedematous, does not pit upon pressure is contained
in Dr. Prudden's observations that the separation of the fibres and the
dilatation of the lymph spaces in the skin of the two myxoedematous
cases which he examined were in those superficial layers of the corium
in which the interfibrillary spaces are much smaller, and the interlace-
ments of the fibres much finer than in the deep layers, which seem
more frequently to be the seat of ordinary oedema. From these smaller
spaces, surrounded by a finer network of interlacing fibres, fluid is
neither so easily driven by pressure nor so easily affected by gravity, as
it is from large spaces surrounded by a coarse network of fibres.
Probably in this difference in the situation of the fluid lies the difference
between the swelling of the skin in myxedema and in ordinary oedema.

From this summary of the symptoms and lesions of myxoedema it
appears that the disease manifests itself by very characteristic symptoms,
which affect especially the cutaneous, the nervous, and the vascular
ins.

( ntnneous system. The skin is swollen without pitting, dry, scaly, and
cold, the hair and teeth frequently fall out, the nails become brittle,
and perspiration is either greatly diminished or absent. The mucous
membranes are also swollen, but their secretion is usually increased.

Nervous system. There is mental sluggishness and impairment, and
insanity is frequent; sensibility, both special and general, is impaired
in about half the cases; the muscles act feebly and sluggishly in all
cases ; the reflex actions are frequently diminished ; speech is slow, and
in more than half the cases hoarse; and numbness and neuralgic pains
are frequently present.

Vascular .*ydem. In the majority of cases the pulse is slow and small,
and the heart presents some abnormality. The blood is often in an
anaemic condition, and very frequently there are severe hemorrhages.

154 HUN, PRUDDEN, MYXCEDEMA.

The temperature, especially the surface temperature, is subnormal, which
may be considered in part a nervous symptom.

The lesions found in the disease are a nearly complete atrophy of the
parenchyma of the thyroid gland, with, in my cases at least, a new
formation of lymphatic tissue in the gland ; a general obliterating endar-
teritis, with consequent left-sided cardiac hypertrophy ; a chronic diffuse
nephritis; an interstitial hepatitis; a degeneration of the suprarenal
capsules ; an atrophy of the fat, and a general oedema or infiltration of
the skin and mucous membranes.

If we attempt to explain the symptoms of the disease by its lesions,
we must seek this explanation either in the disease of the thyroid gland,
in the endarteritis or in the chronic diffuse nephritis ; for the other
lesions are all frequently found at autopsies without having produced
any decided symptoms during life. Certainly the endarteritis and the
nephritis could explain many of the symptoms, such as the hypertrophy
of the left ventricle, the slow, small pulse, the tendency to hemorrhage,
the pallor and coldness of the skin, the effusion into the serous cavities,
the oedema and albuminuria when present, many of the nervous symp-
toms, and the frequency with which life ends in coma or from pneu-
monia. The other symptoms of myxoedema, however, are not to be
explained in this way ; and general obliterating endarteritis, together
with chronic diffuse nephritis, is often found at autopsies of cases which
during life did not at all present the clinical picture of myxoedema.
We are, then, forced to seek for an explanation of the symptoms in the
disease of the thyroid gland. We know almost nothing about the
function of this gland, and are, therefore, entirely unable to predict
what effects would result from the cessation of its functional activity;
and in solving this question must study, 1st, the results of its destruction
by disease ; 2d, the results of its removal in man; 3d, the results of its
removal in animals.

Results of its atrophy from disease. Cretinism is a condition which so
closely resembles myxcedema that the first cases of myxoedema ever pub-
lished were reported by Sir William Gull under the title "On a Cre-
tinoid State Supervening in Women in Adult Life,"1 and in sporadic
cretinism the thyroid gland is either entirely absent or extremely atro-
phied or degenerated, as it is in cases of myxoedema. Dr. Ball, in his
able article on myxoedema,8 points out the above fact, and says, " It is a
suggestive fact in this connection that deficiency of the thyroid body, as
the result of disease, has never been observed except in connection with
cretinism or cretinoid symptoms."

Results of the removal of the thyroid gland in man. In 1883, Prof.
Kocher reported eighteen cases of a disease which he called " cachexia

• Transactions of the Clinical Society, London, 1874, p. 180.
« New York Medical Record, 1826, ii. |

HUN. PRUDDEX, MTIffiDEMA. 155

strumipriva." hut which resembled myxoedema in all respects, and which
:lf lefcHed from the complete removal of the thyroid gland.1

t- then many surgeons have given reports as to the effects of extir-
pation of the thyroid which are somewhat contradictory ; but as a result
of the discussion we mar safely say that in a considerable number of
cases complete extirpation of the thyroid, not only in Switzerland but in

r parts of the world, has been followed by a condition altogether
similar to myxoedema, which is called cachexia strumipriva. Fuhr* states
as a result of his investigations on this subject : "After extirpation of

hyroid two accidents occur: one comes on in women immedia:
and is a form .of tetany which is much more fatal than ordinary tetany,
causing a cramp of the diaphragm ; the second comes on months and
years after the removal of the gland, and is the condition of cachexia
strumipriva."

Ejct'trpation of thyroid gland in animal*. The thyroid gland has been
by a number of experimenters from animals, especially from
monkeys, dogs and cats, and almost all the observers agree that the
result of such extirpation is a condition resembling myxoedema. Prob-
ably the most noteworthy experiments in this direction are those of
lorsley,' who experimented on monkeys, and who found that a
day or two after the operation muscular tremors appeared, which at
once disappeared on voluntary effort ; these tremors increased in intensity
and affected all the muscles of the body ; the animal became languid,
paretic, and imbecile ; then puffiness of the eyelids and swelling of the
abdomen followed, with increasing hebetude ; the temperature became
subnormal ; there was intense pallor and oligaemia, and the animal died
perfectly comatose usually five or seven weeks after the operation. On
studying these symptoms individually closer resemblance to myxoedema
was found than is even shown by the summary given above.

As a result, then, either of the destruction of the thyroid gland by
disease, or of its removal in man or animals, a condition is produced
which very closely resembles myxoedema ; and although in the case of
extirpation of the thyroid the attempt has been made to explain the
resulting symptoms of myxoedema by a cicatricial narrowing of the

nea, or by an injury of the cervical sympathetic, yet neither of these

apts has been in the least successful ; and the symptoms of myx-
oedema in these cases must be regarded as the direct consequence of the
loss of functional activity of the thyroid gland, and not to any secondary

ries of the operation. We do not know what the function of the

loss of which causes the symptoms of myxoedema ; but the

f lymphatic tissue in the thyroid in my two cases tends to

h f. klin. Chir., 1883, toI. », p. 254.
> ArchiT. t ««|mhmrtini Piltriuik m. :Pfcw—hi)linii, UM, *6L m p.m.
* Brtthfc Mitori Umn%\, 1885, i. p. 111.
tol. 96, jio. 1,—Avmm, 1868. 11

156 MORRIS, RADICAL CURE OF HYDROCELE.

confirm Horsley's statement that there is normally lymphatic tissue in
the thyroid gland, and points to a hemapoietic function of the gland.
However obscure the function of the thyroid gland may be, there can
be little doubt that its lesion is the essential lesion of myxoedema.1

SOME REMARKS ON THE RADICAL CURE OF HYDROCELE :

WITH NOTES OF TWO CASES OF EXCISION OF THE TUNICA VAGINALIS,
FOLLOWED BY RECURRENCE OF THE HYDROCELE.

By Henry Morris, M.A., F.R.C.S.,

SURGEON TO THE MIDDLESEX HOSPITAL AND LECTURER ON SURGERY IN THE MEDICAL SCHO.il.

In the history of hydrocele, there have been, both in ancient and
modern times, frequent alternations between what may be called the
closed and open methods of treatment, namely, injections on the one
hand, and tents, setons, caustics, incision and excision, on the other.

Many of the ancients, amongst them Celsus, Galen, JEtius and Paulus
JEgineta, treated hydrocele of the tunica vaginalis testis by excision.
In the eighteenth century Saviard, Garengeot and Le Dran amongst the
French surgeons, recommended the excision of the greatest part of the
vaginal cyst when thick and callous. In England, about the same
period, incision and excision were practised by, and advocated in the,
writings of many surgeons, and particularly by Douglas, Percival Pott
and Joseph Bell. Mr. Sharp was the great advocate of incision, but at
a later period he considered the cutting away of a portion of the tunica
vaginalis advisable. Baker, Robertson and Monro, on the other hand,
had used and recommended the caustic.

Mr. John Douglas, writing in 1755, advised the excision of the tunica
vaginalis even in recent hydroceles, and thought this practice indispens-
ably necessary in hydrocele of long standing. His manner of operat-
ing, which he described in detail, consisted in, first of all, taking away
an oval piece of the skin of the scrotum, in length equal to the long axis
of the hydrocele, and in width at its widest part equal to the widest part
of the tumor. This done, the vaginal sac was opened, the fluid evacu-
ated and the vaginal tissue cut through on each side of the testis and
spermatic cord and removed, so that all the sac, excepting what coven
the spermatic cord and testicle, was entirely removed. Percival Pott, in
a letter to Mr. Douglass, described the method of excision performed by

1 While correcting the proof of this article I learned that the Myxu'dcum Committee of the London
Clinical Society had published thoir report, but I was unuMe to procure ;i oopy of it in time to oompare
with the summary given above, which is necessarily imperfect, because many of the cases on which it
U baaed are imperfectly reported in the journals in whirh 1 bud them.

MORRIS, RADICAL CURE OF HYDROCELE 157

him as follows: " I divide the scrotum (and the sac at the same time)
through its whole length, and then directing an assistant to hold the
lij»s i.f the divided scrotum in a proper manner, I dissect the cyst from
it <>n each side and take away as much of it as I can without injuring
the testicle or spermatic cord." He never found it necessary to remove
any part of the scrotum as Mr. Douglas used to do; and he adds that
he had used the method of excision he described in a great number of
cases for seven years, and had never seen any reason to disapprove of, or
to alter it. Joseph Bell considered that when thickened and hardened,
the tunica vaginalis should undoubtedly be removed, and that great
enlargement of the sac rendered excision occasionally desirable. Cur-
ling, writing in quite recent times, remarks " in old hydroceles, with a
sac greatly thickened, excision of a large portion of the dense tissues is
the best remedy. The cure is speedier and more satisfactory than when
only incision is performed."

Pott at one time classed together injections with the ligature and the
cautery as remedies which, " happily for mankind, were then quite laid
aside." He had fully described and usually practised — under certain
cautions and restrictions — incision, and in some cases excision of a por-
tion of the tunica vaginalis. During the last twenty years of his life,
however, he advocated setons in preference to any other mode of radical
cure.

When Sir James Earle wrote, the seton, owing to the influence of
Pott, and the caustic, through the advocacy of Mr. Else, were the
methods commonly employed in England, but some surgeons had re-
turned to the old practice of incision and excision. The teaching of
Sir James Earle led to the very general adoption of injections, especi-
ally of iodine, and Mr. Pott, having once more altered his opinion, so
far approved of the treatment by injection, that he declared to Sir James
Earle not long before his death, his intention of giving it a fair trial.

Up to this period the quantity of fluid injected was considerable, and
this it was which led to the disasters of the treatment, namely, to extrav-
asation of the injection by the side of the canula into the cellular tissue,
and thus to inflammation, suppuration and sloughing of the scrotum.
In 1834 Sir Ranald Martin published his first paper in the Transac-
tions of the Medical and Physical Society of Calcutta, and in 1842
ril 30th appeared his communication to the Lancet. These papers
led to the general employment of iodine and to the diminution in the
amount of fluid injected. With this change in the manner of injection
there may he said to have ended the occasional disastrous accidents
which formerly occurred.

It may be safely said there is no treatment of hydrocele, however

re, which has not been followed by relapse. In ancient times,

Alhucasis, speaking of excision, alludes to the possibility of relapses

158 MORRIS, RADICAL CURE OF HYDROCELE.

after it. Pott's experience with excision was, so he tells us, uniformly
satisfactory. But Joseph Bell states that he had met with cases of recur-
rence after incision, owing to want of care in obliterating, by adhesive
inflammation, every part of the vaginal sac before allowing the divided
edges of the tunica vaginalis to adhere to the testicle ; and in speaking
of excision of the sac, he says, with a view to preventing relapse, that
the dressing and after-treatment must be the same in every respect as in
simple incision. Thus, it is possible that he may have known of failures
from excision when practised in the incomplete form described by him.
I have known of cases of antiseptic incision followed by recurrence, and
I have seen excision performed with success after both iodine injection
and free incision had failed. I have on several occasions practised exci-
sion, by which, of course, is always meant excision of the parietal portion
of the tunica vaginalis (and some include also that covering the cord),
but not the visceral layer covering the testicle itself. But the only in-
stances in which I have seen recurrence after excision are the two cases
herein recorded. Nor am I aware of any published cases of recurrence
of the hydrocele after excision of the vaginal tunic of the testis in the
manner described by any of the authors who have mentioned it.

The cases I shall relate show that the excision of nearly the whole
tunica vaginalis is not a guarantee of success, but that as in the case of
abscess, dermoid, sebaceous and other cysts, so in vaginal hydrocele a
small corner of the cavity unobliterated, a small portion of the sac left
behind, may serve as the nucleus of a new formation.

To be quite certain of a cure, the vaginal cavity must be entirely ob-
literated either by firm universal adhesion of the two surfaces of the
sac, or by the filling up of the sac by granulation tissue. That a mere
alteration in the secreting character or capacity of the membrane with-
out the formation of adhesions may lead to a permanent cure there is
good reason to believe, from the records of Hutin, Velpeau, Chaumet
and Boinet, as well as from cases in the experience of most modern sur-
geons. But we are quite unable to guarantee a permanent cure in this
way, even though years have elapsed without re-accumulation. A case
of vaginal hydrocele was tapped by Curling twenty-five yean after it
had been " cured " by Sir A. Cooper by injection, the hydrocele having
returned only during the six months previous to the patient coming
under Mr. Curling's notice — i e., twenty-four and one-half years after
the radical treatment.

In the two instances of radical cure which Sir C. Bell examined after
the injection treatment there was adhesion ; and the medium of adhe-
sion had changed into a perfect cellular tissue. The adhesion, to be <
tain of cure, must be general, not partial, nor trabecular in character.
I have, on some occasions after the injection treatment, seen recurrence
of the hydrocele in a loculated or many-chambered manner, owing to

MOKRIS, RADICAL CURE OF HYDROCELE. 159

the trabecular form of the adhesions excited by the first injection. In
such cases a second or third injection has sufficed to complete the cure
by provoking universal adhesion of the two surfaces of the sac.
The following is a good illustration of the condition referred to :

George P., set. forty-three, was sent to me by Dr. Rutherford, of Paul-
1» -rough, on October 5, 1874. For three years he had had an increas-
ing vaginal hydrocele of the right side, which, at the time of admission
to the hospital, was the size of a cocoanut and translucent. On October
7th, thirty-two ounces of typical hydrocele fluid were withdrawn, and
half an ounce of a mixture of equal parts of tr. iodine and water was in-
jected— half of which was withdrawn after a few seconds. On October
17th there was evidently a quantity of fluid re-accumulated, and on
tapping between eight and nine ounces of clear yellow fluid were with-
drawn. This fluid was not all confined in a single chamber, as shown
by its running slowly, and only in response to considerable pressure
and kneading of the swelling, and after turning the canula in various
directions.

Two drachms of a mixture of three parts of tr. iodine to one of water
were injected and left in the sac.

On November 4th, there was no re-secretion of fluid but a good deal
of thickening of the tunic, and some enlargement of the body of the
testis and epididymis — the whole being together the size of an orange.
This gradually diminished.

In August, 1887, nearly thirteen years afterward, Dr. Rutherford,
after seeing and questioning the patient, informed me that there has
never since been any return of the hydrocele.

It is probable that cases which have taken such a course after injec-
tion, as the above, are amongst the most satisfactory and permanent of
cures, and that their process of cure is by universal obliteration of the
sac by adhesions.

But the occasional failure of the injection treatment — according to
some, the failures are as many as twenty per cent, with the iodine
method ; the general opinion that certain conditions of the sac and
testicle are unfit for injection treatment ; the influence which the anti-
ic treatment of wounds has exercised, and-, perhaps, also the success
attending the various modern operations for the radical cure of hernia,
have induced many surgeons to revert to incision and excision.

From a comparison between the closed and open treatment — i. e., the
treatment by injection on the one hand, and incision and excision on the
other — there does not seem to be much, if anything, to choose, either as
to certainty of result or duration of treatment. Nor does it appear that
either the thickness and opacity of the sac, or the simple enlargement,
or enlargement with irregularity in shape, of the testicle ; or the great
size of the tumor, or the encysted nature of the hydrocele, or the previous
failure of the iodine treatment is of itself sufficient reason for reject-
ing the iodine treatment in favor of incision or excision. But, on

160 MORRIS, RADICAL CURE OF HYDROCELE.

the other hand, there seems to be nothing which need deter a surgeon
from incising or excising a hydrocele under either of the above condi-
tions, unless it be that a cutting operation is dreaded by the patient or
is deemed dangerous to the particular individual.

As the complete obliteration of the cavity of the tunica vaginalis is
the only security against a recurrence of the hydrocele ; and as this
result can be obtained as completely by the adhesion which follows
injections as by the granulations which result from incision or excision ;
and further, as relapses are known to follow incision and excision no
matter how thoroughly performed, we cannot yet be said to have dis-
covered a more satisfactory mode of radical cure than the injection of
small quantities of some irritating fluid, after the manner in vogue since
the publication of the papers above referred to by Sir Ranald Martin.

The only cases in which, as it seems to me, it would be better to
incise or excise than to inject, are the following :

1. When we are in doubt as to the precise nature or relations of the
hydrocele sac — e. g., as to whether the tumor is a congenital hydrocele,
or a hydrocele of a hernial sac.

2. In some cases, when hernia, whether reducible or irreducible, com-
plicates a hydrocele.

3. When a foreign body in the tunica vaginalis is the cause of the
hydrocele.

4. When we have reason to think that the hydrocele is caused by, or
associated with, a diseased condition of the testis, for which castration
would be the right treatment.

5. When, as in a case I have recently operated upon, a vaginal hydro-
cele is associated on the same side with an encysted hydrocele of the
cord and a bubonocele. In this last case excision of both the hydroceles,
and the hernial sac, and closure of the pillars of the external abdominal
ring were successfully accomplished at the same time.

After either incision or excision, it is advised, in order to obtain com-
plete obliteration of the hydrocele sac, to scrape gently the surface of
the remaining membrane, or rub it over with iodine, carbolic acid,
chloride of zinc, or some other stimulating fluid, and throughout the
healing process to keep the wound well drained or dressed from the
bottom, with lint or gauze coated with boracic ointment, or iodoform
and vaseline. The advantage of stuffing the wound with lint moistened
with oil, or coated with ointment, instead of with dry lint is, that the
former can be easily removed at the first and every successive dressing
if needful, with little or no pain, and without risk of exciting hemor-
rhage.

The modern " antiseptic incision " differs from the old method of a
long free incision, and subsequent stuffing of the sac. The " antiseptic
in«ision" is practically only the "tent" treatment, employed under

MORRIS, RADICAL CURE OF HYDROCELE. 161

antiseptic dressing, and after stitching the vaginal sac to the skin of
the scrotum. The principle is the same as that of the " tent," and the
.process of cure is the same as that sought for by injection, free incision
and stuffing, and excision.

Cabs I. Hydrocele of untuned *liape of the tunica vaginalis of the tettiele
aial rord : rxcision of the sac; recurrence of the hydrocele, and ultimate
■>n. — Charles G., set. twenty-four, a coachman, was admitted
into the Middlesex Hospital on April 12, 1886, with a large swelling on
the right side of the scrotum, extending upward along the whole length
of the inguinal canal.

Two years before he had received a blow on the right testicle. The
-welled, and was painful for a short time, and very soon a large
swelling occupied the right side of the scrotum, which was tapped on
June 16, 1885, when forty ounces of clear fluid were withdrawn.

The hydrocele gradually refilled, and was again tapped at the end of
November, 1885, when from six to eight ounces were drawn off, and
some iodine was injected ; but the hydrocele returned.

Fio. 1.

On admission the right side of the scrotum and right groin were very
much enlarged, and the skin over the scrotal part of the tumor was
tense and thin. The hydrocele was of an unusual form, being somewhat
constricted — hour-glass fashion — at the top of the scrotum; the part
above was smaller, of an oblong shape, and occupied the inguinal canal;
the part below the constriction was of a rounded or oval shape. The
testicle was plainly seen and felt at the anterior and lowest part of the
scrotum, where it projected below the inguino-scrotal tumor. The
icle was slightly enlarged. The tumor gave a very distinct impulse
on coughing, was dull on percussion, did not diminish in size on pressure,
and was translucent in certain parts.

The diagnosis lay between hydrocele of a hernial sac and a hydrocele

162 MORRIS, RADICAL CURE OF HYDROCELE.

of the tunica vaginalis, the funicular function of which had remained
unobliterated as high as the internal abdominal ring.

The position of the testicle suggested the possibility of the former, but
the history pointed to the latter. The impulse on coughing, and the
shape of the tumor seemed consistent with either, and the harmless
injection with iodine negatived neither the one nor the other.

But the failure of the iodine injection and the very close proximity of
the upper end of the sac to the peritoneum, determined me to excise the
sac rather than repeat the injection ; and if I found the sac communi-
cating by a narrow orifice with the peritoneum, as might have been the
case, whether the sac was of hernial or vaginal origin, I could transfix
and ligature the neck as one commonly does in excision of the sac of a
hernia. Having decided on the excision method, I promised my patient,
rashly enough, as it proved, that I would completely and permanently
cure him of his hydrocele.

On the 14th of April, an incision about three inches long was made
over the front and outer part of the tumor and through the tunica vagi-
nalis, from which several ounces of clear amber-colored fluid were let
out : and then, with a finger in the interior, the sac was found to end
above in a narrow, blind extremity close to the internal ring. The sac
was easily peeled and dissected away from the structures of the cord and
surrounding inguinal and scrotal tissues, and cut off close around the
testicle. The cut edges of the small remaining portion of the vaginal
sac were stitched together with fine catgut sutures, so as to leave the two
layers of the sac in close apposition with one another upon the testicle.

Fio. 2.

Shape of portion of sac removed.

A drainage tube was inserted in the cellular tissue space, from which
the hydrocele sac had been removed, and the edges of the external wound
were brought together by two or three silk sutures. Iodoform cotton-
wool and a spica bandage formed the dressings.

The portion of the sac removed was cylindrical, with an irregular-cut

MORRIS, RADICAL CURE OF HYDROCELK. 1*)3

edge below and a funnel-like prolongation above longer than the index-
v. This proce.-s when tilled with water, which it perfectly retained,
Looked like the distended thumb-stall of a large glove. The sac
somewhat thickened, hut the part corresponding in position with the
external abdominal ring was thinner than the rest.

■ inflammatory swelling followed the operation, but the patient
made a good recovery, and left the hospital well on May the 11th, four
weeks all but a day from the operation.

On November 2, 1886, he returned to the hospital with a swelling on
the same side of the scrotum, which had commenced to form in the
beginning of October, just six months after the excision of the former
hydrocele sac.

On admission the swelling was tense, elastic, translucent, and of a
very irregular shape. It was quite hard, gave no impulse on coughing
and was situated in the upper part of the scrotum reaching nearly as
high as the external abdominal ring, being prevented from hanging
down by the tough and contracted scar-tissue in the scrotum.

There was no possibility of doubting that it was a hydrocele of that
small remnant of the old sac which had been left at the operation.

On November 3d an incision two inches long through the old scar was
made into the sac and two ounces of clear straw-colored fluid of ordinary
hydrocele character were drawn off.

The cavity was stuffed with boracic lint and iodoform dressing was
applied over the wound. No sutures were used. The lint stuffing was
removed on the seventh day and a drainage tube was -substituted. A fair
quantity of pus was discharged for two or three days after the removal
of the lint, but on the twelfth day after the operation it was barely pos-
sible to introduce the drainage tube, and on the eighteenth day the
patient left the hospital quite well. He has remained well since.

Case II. Old double hydrocele. One sac treated by excision ; the other
by repeated tappings. Reaccumulation on the side treated by excision.
Ultimate cure of both hydroceles. — Thomas K., set. thirty-four, a carpen-
ter, was admitted on April 12, 1887, on account of a large double hydro-
cele which he had had for five or six years. Just before the appearance
of the hydroceles he strained himself, and soon began to suffer pain in
his testicles; ever since then there has been a gradual increase in the
scrotal swelling. No treatment has ever been employed until his first
visit to me, when I drew off twelve ounces of turbid, yellow fluid from
the right, and twelve ounces of rather turbid, reddish fluid from the left
tunica vaginalis. Before the tapping the scrotum was seen as a very large
rigid binoval swelling hanging down in front of his thighs. The division
between the two sacs was indicated by a vertical depression in the scro-
tum. Each portion was hard, tense, and slightly elastic but not fluctu-
ating; neither hydrocele transmitted light or was tender on manipulation.

On puncturing, a great deal of resistance was experienced to the transit
of the trocar — due to the thick and almost cartilaginous toughness of
the tunica vaginalis. After the fluid was removed each testicle was felt
to be much and irregularly enlarged.

Immediately after the tapping each hydrocele began to refill, and he
was, therefore, admitted into hospital on April 27th for radical treat-
ment. Owing to the chronicity of the disease, the enlargement of the
s, and the great thickness of the sac, the case was not deemed well

164 MORRIS, RADICAL CURE OF HYDROCELE.

suited for injection of iodine, and excision was consequently determined
upon.

On April 30th an incision three inches in length was made over the
anterior surface of the right hydrocele down to the tunica vaginalis.
The vaginal sac, which was very tough and as thick as an old-fashioned
penny-piece, was next opened, and after evacuating its contents, was
incised to nearly the same extent as the integuments. The whole of the
tunica vaginalis was then excised, except that which covered the testicle
and a narrow strip immediately adjacent to the testicle at the lower part
of the scrotum.

The testicle was larger than normal, and irregular in shape, but other-
wise appeared healthy. The tunica vaginalis, especially that over the
testis, was highly injected, and much of its surface was besmeared with a
yellowish-white stringy lymph, which here and there disguised the vas-
cularity of the vaginal membrane. After removing these flakes of lymph
a strip of boracic lint was lightly introduced into the wound so as to sur-
round the testicle, and cover the remnant of the parietal portion of the
tunica vaginalis ; a drainage tube was inserted at the upper part of the
wound, and sutures were used to bring together the edges of the wound,
except where the lint and drainage tube projected. Iodoform was dusted
over the surface of the incision, and a packing of boracic charpie and a
spica bandage served as dressing.

The strip of lint was removed on the third day ; and the sutures on
May 7th. Some inflammatory swelling and purulent discharge followed
the operation, and the greater part of the wound healed up by granula-
tions. On May 28th, as there was still a daily purulent discharge, due
to the bagging of about a drachm and a half or two drachms of pus at
the back of the right side of the scrotum, a counter-opening was made ;
a few days later, a seton, consisting of six carbolized horsehairs, was
passed through the original wound and the counter-opening. One hair
was removed every other day, and at length the sinus was closed after
the Avithdrawal of the last hair.

Meanwhile a reaccumulation of hydrocele fluid occurred at the lowest
part of the scrotum as a secretion from the remnant of the tunica vagi-
nalis which had not been removed. The hydrocele formed quite a well-
defined round cyst-like swelling ; and on tapping it one ounce of clear
pale fluid escaped. By June 10th this new hydrocele sac had refilled,
and therefore it was incised and stuffed with boracic lint, and daily
restuffed until it was closed up by granulations.

The left hydrocele was tapped on the day of the excision of the right
sac (April 30th), when between eight and nine ounces of fluid were
withdrawn. It was tapped again on May 16th, when two ounces were
taken away, and once subsequently, when about one ounce was removed.
After this the sac did not again secrete, and the man was discharged
with both hydroceles cured on June 18, 1887.

He has since been seen several times, and is quite well, except that
both testicles are still irregular in outline, and somewhat larger than
normal.

The length of time between the operation and his discharge from
hospital \v:is exactly seven weeks.

London, Hay 10, 1888.

REVIEWS.

Gout in its Relations to Diseases of the Liver and Kidneys. By
;«X)SE, M.D., F.R.C.S. Fifth edition. 12mo. pp. 175. London:
EL K. Lewis, 1888.

Address on the Therapeutics of the Uric Acid Diathesis (the
Treatment of the Gouty Constitution). By I. Burney Yeo, M.D.,
F.R.C.P. 8vo. pp. 17. London : The British Medical Association, 1888.

Dr. Roose's excellent little book is well known by its former editions.
The medical profession, and many not engaged in the healing art, both
in Great Britain and America, are familiar with its practical teachings.
Its translations into French and German have been well received on
the Continent. Any extended review of it in these columns would,
therefore, be out of place, were it not for the general importance of the
subject, and the fact that the present edition is not a mere reprint, but
contains the results of the author's more extended personal observa-
tion, and of his watchful scrutiny of the recent publications in every
quarter where gout excites attention. And where, in those climes in which
Englishmen and Germans have made their homes, does this protean dia-
thetic malady not excite either the absorbing interest of many of the
foremost citizens for the present, or their anxious apprehensions for the
future?

The first three chapters — pages 1 to 59 — are devoted to general con-
siderations with regard to gout, and to a concise critical review of the
theories entertained, both past and present, in regard to its nature.

The views of the author are embodied in the following propositions,
which, if not wholly novel, are characterized by a very satisfactory
definiteness of statement in regard to a subject too often vaguely and
indefinitely set forth :

1. Uric acid, in the form of sodium urate, is the materies morbi of
gout.

2. The deposits of sodium urate in the joints is the cause of the gouty
inflammation.

3. This substance is produced in excess, as a result of the imperfect
transformation of albuminous substances.

4. This imperfect transformation is, for the most part, due to func-
tional disorder of the liver, or to excessive supply of nutritive materials,
or, as often happens, to a combination of these causes.

3o long as the excess of uric acid is eliminated by the kidneys,
decided attacks of gout may be absent ; but the symptoms described as
pertaining to the uric acid diathesis are liable to be present.

6. The kidneys are apt to become secondarily affected, owing to the

lb'() REVIEWS.

irritation set up by the excess of uric acid and other products of defective
metamorphosis and by deposits of urates. Primary disorder of the
kidney is not a necessary factor in the production of gout.

7. In the majority of cases of chronic gout increased formation of uric
acid is associated with defective elimination by the kidneys.

8. The symptoms of nervous disorder in gout are due to the action of
the materia peccans in the nerve centres.

Chapter IV., upon the causes of gout, is rather suggestive than exhaus-
tive. The author is disposed to assign a comparatively low position to
heredity as a predisposing influence. The vagaries of hereditary gout
are briefly pointed out and explained, and the influence of personal
habits in fanning the smouldering tendencies into activity are empha-
sized. With regard to geographical distribution, gout is said to be more
common in England and in the southern provinces of Italy. The part
played by sex, age, climate and season secures due attention, but to
dietary excesses, especially excesses in albuminous food, must be assigned
the principal etiological role.

"There can be no doubt that errors in diet are the most potent cause, both
of functional derangement of the liver and also of gout, and that when, as
too often happens, deficient exercise is superadded, the development of the
gouty diathesis is, in many cases, only a question of time."

The author holds that the popular view in regard to the use of sugar
as increasing gouty tendencies is correct, not that it promotes the forma-
tion of uric acid, but that, like starch, being readily oxidized, it stands
in the way of the normal disintegration of the albuminoid constituents
of the body.

The use of alcohol in the form of spirits is not regarded by the author
as a cause of gout, except as it unfavorably affects the liver and kidneys
and thus interferes with elimination. The light, well-fermented wines
he also regards as not liable to produce gout, but thinks that the full-
bodied wines, containing much unfermented matter, are potent for evil.
Much importance is justly ascribed to the evil effects of malt liquors.

Chapter V. treats of the irregular manifestations of gout, and espe-
cially of the visceral and cutaneous affections to which gouty persons
are prone.

In Chapter VI. the hepatic and renal disorders connected with gout
receive the attention due them. The author discusses the relation of the
various forms of albuminuria to gout with thoroughness. He regards
the renal disorder as secondary to the litluemia, and the gouty kidney
as probably a result of the irritation due to the excretion of imperfectly
metamorphosed substances. Even the occurrence of albuminuria in
young subjects with a gouty family history is looked upon as "more
than a mere coincidence."

Dr. Roose supports the view, too little regarded by life insurance
examiners, that " the gouty constitution undoubtedly tends to shorten
life, mainly by causing serious lesions of the heart and kidn<

The concluding chapter, VII., is devoted to the discussion of the treat-
ment of the gouty diathesis, of the attack of articular gout, and. finally,
of the more important of these disorders, which are the direct result
the gouty dyscrasia.

This part of the work is eminently satisfactory. It is applied medi-

ROOSE, YEO, GOUT. 167

cine — the art of healing. The directions are clear, the reason for them
obvious, their application practicable. The author insists upon the
- lutr necessity " of making a special study of each patient.

- are to be given, but in such amounts only as are required to
meet the wants of the system. Farinaceous food, such as bread, rice
and potatoes, should be used very sparingly ; pastry is, of course, for-
bidden. A little fruit may be used. Alcohol is not permitted, save in
cases where it is necessary to digestion. Old whiskey or brandy well
dilated, <>r sound claret or hock, are best suited for gouty subjects.
Effervescing wines and malt liquors are strictly interdicted. Milk
should be used sparingly. The quantity of food taken is, in every case,
to be strictly regulated. General hygiene, bathing, exercise, the use of
mineral waters and the various spas of England and the Continent are
carefully reviewed. The remarks upon the medicinal treatment of the
gouty diathesis are chiefly directed to the regulation of the functions of
the liver, bowels and kidneys.

The attack of articular gout is treated bv purgation by calomel or a
saline or both, followed by colchicum and alkalies. The limb is treated
by vapor baths and rolled in wool. The local use of belladonna is
advantageous. The diet is of the strictest. The treatment of the local
disorders of the gouty is briefly but practically laid down.

Dr. Yeo's address, which was delivered at the opening of a disc
of the subject in the Section of Pharmacology and Therapeutics at the
Annual Meeting of the British Medical Association, held in Dublin,
August, 1887, is, of necessity, less formal and more concise. It is not,
however, less definite and emphatic. It also is eminently practical in
character. The author claims, as a good working definition of gout, that
which he has elsewhere given, namely, " gout is a disturbed retrograde
metamorphosis." The schematic arrangement of the * principal morbid
conditions dependent on, or associated with the uric acid diathesis"
which follows, is at least as discouraging as instructive ; nor can we
find much comfort in the list of the " principal proposed remedies for
affections connected with the uric acid diathesis," a list beginning with
hot and cold water, and ending with mineral waters and baths, but
including between these mild extremes several very active drugs, mostly
poisonous, and all nauseous.

Dr. Yeo also insists upon the special study of each case, especially
with regard to digestive peculiarities. Our object is to construct, in
accordance with, and in subordination to, certain generally admitted
truths, a diet which shall be readily digested, and which does not tend
to excite acidity and undue fermentation in the alimentary tract ; and
that diet will differ with different persons. The author recognizes the
neurotic factor in gout, and lays stress upon the fact that, at the present
day, the nervous manifestations of gout are not seldom encountered in
persons who are delicate, with small appetites, and who consume a mini-
mum rather than a maximum amount of food.

As regards alcohol, the malt liquors are most prejudicial ; low grade
wines next in order. For the rest, the peculiarities of each patient
must be regarded. We believe that, in regard to the use of alcohol in
the gouty diathesis, the author errs on the side of liberality. The impor-
tance of water as a beverage, especially of hot water, is insisted upon.

168 REVIEWS.

The first place among medicines in the treatment of both the uric
acid diathesis and its various morbid manifestations is given to col-
chicum, which is evidently regaining its old favor, not as the result of
new knowledge, but because experience has given us nothing better.
Yeo maintains that, so far from being a dangerous vascular depressant,
colchicum, in moderate doses, is capable of restoring regularity and
strength to the irregular and feeble pulse of chronic gout, with subacute
exacerbations. He adds :

" I trust that the absurd prejudice against this most valuable remedy which
has been excited in the mind of the public, will be removed, for I find main-
gouty persons who, much to their disadvantage, positively refuse to take
colchicum, because they have been told that it is ' such a dangerous drug.' "

It is to this popular prejudice against colchicum that must be ascribed
the extraordinary statement of Ebstein, that it is preferable to relieve
the pain of the gouty paroxysm by hypodermatic injections of morphine,
which, he says, act " quicker, more easily and with less danger." In
this matter, Yeo, and we are in full accord with him, joins issue with
Ebstein utterly. The internal use of opiates in gout, save under ex-
ceptional circumstances, is indefensible. Gout is a disease of defective
elimination ; opium and its derivatives depress in a remarkable manner
all the excretory functions except that of the skin ; a small dose of
morphine will often, in the gouty subject, produce clay-colored stools.

The salicylates, the benzoates, guaiacum, the iodide of potassium and
the alkalies receive, in turn, brief but practical consideration. The
author holds that physicians are, at the present time, disposed to ex-
aggerate the value of the lithia compounds as compared with those of
potash and soda.

Yeo's views upon the subject of mineral waters are entitled to especial
consideration ; and the indications which he gives for the employment of
the waters of the various springs, albeit all too brief, constitute, perhaps,
the most valuable portion of the address. The explanation of the fact
that all kinds of mineral waters have been recommended in the treat-
ment of the gouty constitution, and the further fact that springs of the
most varied composition have been used with success, he finds in the
following conditions, which are common to them all :

" 1. There is the quantity of water, more or less pure, taken into the body
under regulated conditions daily. I have already attempted to estimate the
value of this remedy.

" 2. There are, in many of these spas, the altered mode of life ; the regular
exercise in the open air, the modified diet, the early hours, the absence of
business cares.

" 3. In many foreign spas there is the drier and hotter Continental climate ;
and

"4. The stimulating effect to excretion and 'tissue change' which the
laths, douches, frictions and manipulations applied, at most of them, induce.''

Any direct medicinal effect exerted by particular vraten is, over and
above these attributes, common alike to the "indifferent thermal"
springs, and to all the "there. J. C. W.

SMITH, ABDOMINAL SURGERY. 109

Aiu'minai, Surgery: By J. Greig Smith, M.A., F.R.S.E., Surgeon to
>1 Royal Infirmary, etc. Second edition. 8vo.pp. 77G. Philadelphia:
P. Blakiston, Son & Co., 1888.

This work has been increased in size by the addition of 170 pages,
and this has been done through elaboration of the subjects treated in the
first edition, and by the addition of two new sections, the first on supra-
pubic cystotomy, of fifty pages; and the second, on operations for
Rbdominal injuries and inflammations, of seventy pages. The latter
treats of gunshot-wounds, stab-wounds, ruptures of the intestines, uri-
nary bladder, gall-bladder and solid viscera ; perforating appendicitis ;
perforating ulcer of the stomach ; perforating typhoid ulcer ; purulent
collections in the pelvis ; and tubercular peritonitis.

In his remarks on " The Operating-Table," Mr. Smith recommends
that this should be according to the height of the operator, if he is to
stand, and tall enough to secure him against spinal strain or muscular
fatigue. This will require several inches to be added to the height of
an ordinary house table. He still recommends a rubber covering for
the abdomen, with a large opening to operate through, the edges of
which are to be made adherent by plaster material. This has been sus-
pended here, by the use of a rubber receiver with apron-conduit, to be
placed between the patient and the table, to catch discharges, ovarian
fluid, irrigating water, etc. ; which it does effectually, and keeps the
woman and table from being soiled, except where the body is uncovered
and may be easily wiped clean and dry.

Ether is recommended as an anaesthetic, an exception being made in
favor of chloroform for old patients and bronchitic subjects. The use
of morphia is objected to for the after-treatment, in all cases where it
can be avoided, as " it lowers the functional activity of the intestines
and favors the production of tympanites." " The patient is always
brighter and better without it."

The author objects to the use of " cold water, and particularly ice to
.suck," for allaying thirst, and recommends warm water instead, as less
likely to provoke emesis. We do not think this plan, prevalent here
many years ago, would suit in our climate, or the subjects to be treated.
His recommendation to allay thirst by a warm water enema is excellent,
and will be found particularly useful where there has been much blood
lost, to give rise to it.

We are glad to see that Mr. Smith gives Dr. McDowell due credit as
the first ovariotomist, and that he entirely disagrees with Mr. Tait in
his attempt to establish the claim for Houston, whose report does not
show that he tied the pedicle or removed a tumor. If Houston had
been the American instead of McDowell, no doubt the claim of the
former would have been measured differently against that of the latter.

Under the heading of "Fallopian Pregnancy," the author says,
Most men are now agreed as to the truth of Tait's opinion, that all
examples of extrauterine gestation are in the beginning either wholly
or partially Fallopian." We find it much more difficult to account for
certain ectopic pregnancies, where the placenta has no pelvic connec-
tions, upon this basis, than to believe that the growth has beena6 ori-i
abdominal ; and we see no reason why an ovum may not fall into the

170 REVIEWS.

peritoneal cavity instead of the funnel-shaped end of the oviduct. Mr.
Smith doubts the ability of a gynecologist to diagnosticate a tubal preg-
nancy before rupture, which is not in correspondence with the views of
many able men here and in his own country. Dr. Aveling, particularly,
holds to the opposite opinion, and denies the danger of electricity in
destroying an early ectopic fetus ; the results of forty American cases
show that the danger is far less than by any other foeticidal method.

In the chapter on " Csjesarean Section," our author says, " There is
little doubt that it was practised among the Jews from very ancient
times." This, our best Jewish medical scholars who have examined
their records critically, deny. Simmons is quoted (1799) as holding to
the belief that the operation in 1500, at Siegerhausen, was upon an
ectopic case. This would have been a far greater feat at that day than
the performance of gastro-hysterotomy, in which five, out of a list of six
women, have been successful in operating on themselves, and two more
upon other women.

On page 295, the United States is credited with 124 Csesarean opera-
tions; it should be 170. Great Britain with 131 instead of 151 ; and it
is stated " that 60 improved Caesarean operations have been performed."
In fact, there have been more than 100 ; 20 of them in the United
States. The last 7, in New York and Philadelphia, saved 6 women.

Abdominal exsection of the living and viable ectopic foetus has been
performed thirty times, with five recoveries ; four women were saved out
of the last ten. Total exsection of cyst and placenta when possible is
an essential of success.

Limited space will not permit of a more extended critical examina-
tion and notice. As we anticipated in our last review, the first edition
very soon went out of print ; and a second was demanded long before it
could be prepared. The second is quite superior to the first edition,
and is a much more comprehensive treatise. The new operation on
hysterorrhaphy, of Olshausen, Sanger and Kelly, has not been described.
It has been tested here by Prof. Lusk and Dr. C. C. Lee, who are pleased
with its prospective merits. Mr. Smith has certainly produced a valu-
able work ; much the best of its kind in the English language, and
particularly acceptable to students in abdominal operations preparing
for some special case. R. P. H.

Nouvelle Methode de Traitement de la Diphtui:kii.. Par le E)oc-
teur Guelpa, Membre de la Soci6t6 de m6decine pratique ; Membre cor-
respondent de la Soci6t6 de climatologie algenenne. Paris, 1887.

This " new method " consists essentially of repeated irrigation of the
affected parts. The solution employed by Dr. Guelpa, in his cases, was
composed of perch loride of iron, 5-10 parts per 1000 ; but, believing his
results to be largely, if not solely, due to irrigation, he admits that solu-
tions of other substances, such as boric and carbolic acids, might be quite
as efficacious as that of the iron salt. The instrument employed is a
syringe, and when the application is made to the pharynx the nozzle is
slipped along between the cheek and the dental arch, the fluid passing
in behind the last molar. By this manoeuvre, the forcible opening of

BELL, MANUAL OF OPERATIONS OF SURGERY. 171

the mouth is rendered unnecessary. In washing out the nasal passages,
the injection is made through one of the nostrils with sufficient force to
M its return through the other.
The author's first experience with this method was obtained at S6tif,
in Algiers, where a severe epidemic of diphtheria followed in the wake
of one of scarlatina, and prevailed extensively during 1878, 1879 and

•. In these cases, more than 200, the percentage of mortality was
about 15. and this favorable result was obtained in spite of the fact that
among them are included : 1. Cases in which the nasal fossae were filled
with false membranes, and impermeable to injections when first seen. 2.

- which were seen for the first time only a few hours before death.

hildren at the breast, and those who, at the first visit, were suffering
from diphtheria of the larynx.

Guelpa claims that, by this method faithfully carried out from the

uning. the mortality can be reduced to less than ten per cent.
Believing the method to possess great prophylactic value, he advises
that the nasal passages be washed out, even when the disease is limited
to the pharynx, and states that in families in which not only the patient,
but the healthy members, used the injections, the disease did not extend
to the latter.

The author was given an opportunity to test his treatment in one of
the hospitals of Paris (l'hopital Trousseau), the result being a mortality

out of 19 cases. It is, however, only fair to add that obstacles were
placed in the way of its thorough application, and that, after an analysis
of the cases, Guelpa contends that there was, in reality, but one case in
which the treatment could be truly said to have failed. Certainly the
method is well worthy of a trial in a disease in which, so far as treat-
ment is concerned, there is so much to be desired. F. P. H.

A Manual of the Operations of Surgery, for the use of Senior
Sri- dents, House Surgeons and Junior Practitioners. By Joseph
Bell, M.D., F.R.C.S., Consulting Surgeon to the Royal Infirmary, and
Surgeon to the Royal Edinburgh Hospital for Children. Sixth edition,
revised and enlarged. Illustrated. 12mo. pp. 326 and index. Edinburgh:
Oliver & Boyd, 1888.

Tuts manual of the operations of surgery, though less profusely illus-
trated than could be desired, otherwise admirably fulfils the author's
aim in compiling it. He has wisely and clearly carried out his object,
" to describe as simply as possible those operations which are most likelv
to prove useful, and especially those which, from their nature, admit of
being practised upon the dead body."

The author has been most judicious in keeping his book free from
all mention of methods of wound treatment and of dressings and appli-
ances. Only the actual steps of operation, as a rule, are described, but,
here and there, a few well-chosen words, in regard to choice of operation,
i Somatology and history, are introduced. Very many modern and
radical operations receive no mention or reference, but possibly the

vol. 96, ko. 2.— ACOUtT, 1888. 12

172 REVIEWS.

author did not regard some of them as coming within the scope of his
work, as he, in the preface, distinctly disclaims any attempt to have the
book complete. No instruments are pictured, and for them the author
refers the reader to the illustrated catalogues of the instrument makers.

The first few pages of the volume are taken up with very useful,
full-page illustrations of a man in various stations, upon whom are drawn
the lines of incision for all ordinary operations. Then follow excellent
chapters upon ligations, amputations, excisions, etc., including brief
synopses of the conventional operations upon the special organs, abdomen,
chest, bladder, etc.

All of the statements which are to be found in the book cannot be
allowed, however, to pass without challenge. Thus, for instance, the
author has seen fit to introduce statistics, and to base upon them argu-
ments and conclusions. With these statistics we must find most serious
fault, for they are ancient — that is, preantiseptic : a common source of
grave error in nearly all books — perhaps excusable, in part, by lack of
great aggregations of cases treated by modern methods, but sufficient
numbers have already been published for authors to make at least a
start in the right direction. By one or two trangressions of the set
limits of the work, opportunity is given for other challenge, for, in
speaking of excisions, the statement that " synovial membrane, however
gelatinous or thickened looking, really requires very little care or notice "
is entirely contrary to the principles of modern surgery and the teach-
ings of pathology, which could not better be proved than by the de-
scription in the same paragraph of what follows if the recommended
plan of treatment is adopted. "It" (the synovial membrane) "will
disappear of itself, partly by sloughing, partly by absorption during
the profuse suppuration " which is expected to follow. The old-fashioned
crucial incision for trephining and other purposes is put forward as the
best, whilst the latter operation is recommended for performance only
when there are symptoms of compression present, even though the frac-
ture be a punctured or compressed one. Viewed, as a whole, the work
is to be highly commended, and its place will be amongst the verv best
of its class. T. S. K. M.

Dissolution and Evolution and the Science of Medici arm: an

ATTEMPT TO COORDINATE THE NECESSARY FACTS OF PATHOLOGY, AND

to Establish the First Principles of Treatment. By C. Piti n i i>
Mitchell, M.R.C.S. England, Author of the Treatment of Wounds as
Based on Evolutionary Laws. London : Longmans, Green & Co., 1888.

The object of this book is "to disseminate some new application! of
Mr. Herbert Spencer's leading generalizations. The sustaining elements
of the sympathetic philosophy are the doctrines of evolution and di
hit ion. The design is to inquire whether these may not be made fer-
tilizing principles for large collections of the data of pathology, and thus
the means of practice for the physician and surgeon. . . . To make
all diseases from a whitlow to mania one in principle, by cause and
effect, is an aid to thought." That such a consummation is deniable
will he granted The difficulties of approximating any collection of

MITCHELL, DISSOLUTION AND EVOLUTION. 173

facte and theories to a philosophical system must depend on imperfec-
tions in both parts. In the present instance there is no attempt to
involve the doctrines of Mr. Spencer in all their bearings; and as the
accuracy of the definitions of evolution and dissolution as abstractions
cannot be questioned, want of success must depend on the limitations
of pathology.

A careful study of the volume shows that the author has succeeded in
his task to a remarkable degree. Beginning with general processes,
inflammation and suppuration are shown, as far as can be demonstrated
at present, to have all the characteristics of dissolution, that is, " disin-
tegration of matter and concomitant absorption of motion; during which
the matter passes from a definite, coherent heterogeneity to an indefinite,
incoherent homogeneity ; and during which the retained motion under-
goes a parallel transformation." Local amemias, hyperseraia and hemor-
rhage are also shown to be dissolutional processes. Resolution and
repair are then studied as evolutional changes, or those in wThich there
is an " integration of matter and concomitant dissipation of motion ;
during which the matter passes from an indefinite, incoherent homo-
geneity, to a definite, coherent heterogeneity, and during which the
retained motion undergoes a parallel transformation." These transla-
tions are so natural as to require no detailed explanation of the proofs
cited.

Coagulation of the blood, thrombosis and embolism, gangrene and
coagulation-necrosis and some other metamorphoses may also be passed
over as easily understood from the terms.

The changes induced by vegetable and animal parasites, being for
the most part inflammatory, are naturally assigned to the dissolutions.
The infective tumors, or granulomata, having a tendency to the forma-
tion of cicatricial tissue, their life history "shows alternations of disso-
lution and evolution." By a curious oversight it is said (page 62) that
the nature of the agent producing glanders is unknown.

A great deal of space, as we should expect, is devoted to the neo-
plasms other than those just mentioned. To show that they are subject
to the general rules is not very difficult, but the author has studied them
from so many points of view, and some of these so novel, as to make it
one of the most interesting chapters in the book. To give even an out-
line of this part would lead us beyond the limits of this article, and we
must content ourselves by referring the reader to the original.

Nowhere is the value of the leading principles better shown than in
the part on special diseases, where the observance of the rules leads to
the rejection of the old theory of sclerosis, fibrosis and cirrhosis, and the
acceptance of the one undoubtedly correct, and now gaining ground,
that the growth of connective tissue in chronic affections is evolutionary,
not an inflammatory process.

Curiously enough, the author has left the inviting field in pulmonary
diseases furnished by the microorganisms, and has taken up the view —
we must admit greatly improving it — that the condition of the pul-
monary arterial blood is of radical importance in pneumonia as well as
in phthisis. Although the arguments are plausible, and we would not
deny a predisposing influence to the altered blood, we think the author
underrates the microbic factors in the common pulmonary diseases.
ainly nothing would be more natural and satisfactory than to look
on phthisis as a series of dissolutions and evolutions simultaneous and

174 REVIEWS.

successive, due to causes from without. Remarks ou nervous and mental
diseases and certain fevers and diathetic diseases end this part of the
work.

A short section on heredity and disease discusses this vexed and intri-
cate question in a critical and conclusive manner, and it is shown why
diseases are, for the most part, refractory to transmission by descent.
Finally, a study of " organic equilibrium " leads to a recognition of the
vis medicatrix natures, its tendencies and limitations, and the necessity
for the study of causes and their avoidance or removal in the treatment
of disease.

Conceived in a broad and scientific spirit, this book is carried out
with a recondite knowledge of facts and theories thoroughly in keeping
with it. Instances of special pleading are rare, and, as a rule, when the
author has failed in making good his object, the fault has been due to
the limitations of pathological science. On the other hand, this science
receives a new and fascinating aspect, and many fresh fields of view are
opened up by a study of " dissolution and evolution."

The book is gotten up in a degree of luxury uncommon among works
of its class. G. D.

Studies in Pathological Anatomy, especially in relation to
Laryngeal Neoplasms. Part I. Papilloma. By R. Norris Wol-
fenden, M.D. Cantab., and Sidney Martin, M.D. Lond. Loudon: J.
& A. Churchill, 1888.

This appears to be the first of a series of contributions to the path-
ology of the larynx. Part I., after some preliminary remarks, gives a
concise and accurate description of the etiology, clinical course and ter-
minations of benign new growths of the larynx, and then takes up the
subject of papilloma. The methods of examination of these growths
are clearly described, and the pathological anatomy presented in terse
and vivid language. The important questions of diagnosis between
these growths and epithelioma, and of the degeneration of papilloma
into epithelioma, are promised discussion in connection with the latter
disease.

The plates illustrating this fasciculus cannot be too highly praised.
Not only are they beautiful works of art, but their histological accuracy
is beyond criticism. Should the work be completed according to the
promise of Part I., it cannot fail to form a valuable addition to the
study of pathological auatomy as well as laryngology.

PROGRESS

MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

FRANCIS H. WILLIAMS, M.D.,

ASSISTANT PROFESSOR OF MATERIA MF.DICA AND THERAPEUTICS IN HARVARD UNIVERSITY.

Glycerin* as a Laxative Enema.

All observations agree as to the satisfactory and even brilliant results of
this use of glycerin. First, Anacker {Deutseh. med. Wochenschr., 1887, p.
823), having discovered that "das Purgativ Oidtmann," a proprietary medi-
cine of much renown, and likewise given by enema in quantities of from
xx to xxx rt^, was mostly glycerin, tried this substance alone. "With enemas
of fifty drops his success was complete and unvarying. After him, Varnossy
( Wien. med. Pnstc, 1887, 48, and Ther. Monatshefte, March, 1888, p. 140) made
trial of it in 150 cases of all ages, with "astonishing" results, using tr^ xxx.
Next Sunder Mii?ich. med. Wochenschr., 1888, vol. i. 9) reports having always
seen the best results ; he uses 3j on an average. In smaller quantities he
recommends it especially for children. Finally, Boas {Deutech. med. Wochen-
schr., June 7, 1888, p. 469) has had the same gratifying success with supposi-
tories of glycerin, which, from being readily handled, etc., have advantages
over the syringe and injection, if equally efficient. Boas uses some special
form of hollow suppository in which vci xv are placed. The dejection follows
in fifteen to twenty minutes. Thus these observers agree in recording remark-
able success. Glycerin seems to act cito, tnto et jumnde and to have added to
our resources. No one has anything to record against it except that it cannot
be used when there is ulceration. Neither the injection nor the movement
causes pain, and, according to Seifert, no tolerance is established. The move-
ment should take place within half an hour.

Calomel as a Diuretic.

Among many observations on this use of calomel as a diuretic, Prof.

uxagel makes the following communication to the Ther. Monatshefte

(May, 1888, p. 263). After extended experience, he declares calomel to be

"extraordinarily valuable" in the dropsy of heart disease; on the contrary,

ineffective in the dropsy dependent upon renal or hepatic affections.

176 PROGRESS OF MEDICAL SCIENCE.

His formula is :

R. — Hydrarg. chlorid. niitis gr. ijss.

Sacchar. lact. gr. viij.

Take ten such powders at the rate of four a day.

The urine does not begin to increase till the third or fourth day. Nothnagel
has seen an amount previously Ijx rise to ^clxv to Jccxxx ! After reaching
the acme it sinks again in the next eight days. After a rest of two to four
weeks the treatment may be repeated. Should no result follow in four days,
the administration is stopped and resumed after eight days. In case of a
second failure this treatment is given up. The mouth needs especial care.

In the main, these statements accord with those of Rosenheim, to whom
we owe the revival of this old remedy (Deutsch. med. Wochenschr., Nos. 16 and
17, 1887). He gave the same dose, t. i. d. The first effects were observed
on the third or fourth day, when the remedy should be stopped. Both
increase and decrease are rapid. In only a few cases could Rosenheim obtain
a second diuresis on repeating the remedy. Out of sixteen cases he had
stomatitis in ten, diarrhoea in eight. Other mercurial preparations are diu-
retic, but calomel is the best. The condition of the diuresis, according to
Rosenheim, is mercurial ization — i. e., the absorption of mercury into the
system, as proven by its presence in the secretions.

Analgesic Use of Antipyrin.

Gunther (Deutsch. med. Wochenschr., May 17, 1888, p. 406) has made
much use of a» thirty to fifty per cent, solution subcutaneously. In a case of
fresh fracture, an injection made at its seat, deep into the tissues, enabled him
to apply the first apparatus without the slightest muscular contraction. It
has been of great service in laryngeal phthisis with cough and loss of sleep.

Berdach ( Wiener med. Wochenschr., 1888, No. 11) says a fifty per cent,
solution in distilled water is adapted to all painful conditions. The effect
appears in a few seconds and lasts at least six hours.

Ox the Use of Codeine to Relieve Abdominal Pain.

The fact that many practitioners still prefer opium to morphine in the
treatment of abdominal pain, led Lauder Brunton (British Medical Journal,
1888, i. 1213) to question whether some other alkaloid was not more powerful
than morphine in cases of this sort. Barbier, in 1834, found that codeine had
an especial action in lessening pain from irritation of the solar plexus, while it
did not disorder digestion, and rather aids the action of the bowels. The son
of Robiquet, the discoverer of the drug, made some observations which did not
agree with those of Barbier, but the disagreement may have depended on some
impurity. Berth6 confirmed Barbier's views, and found that the drug Lessened
i In' irritability of the intestine very greatly. Brunton concludes from these
experiments that codeine is likely to be of value in relieving abdominal
pain, and has employed it with great success especially in painful affections "t"
the intestine and lower part of the abdomen. It is particularly valuable
where morphia is to be avoided on account of the condition of the heart or
lungs, or where it is desired not t<> interfere with the action of the bow

THERAPEUTICS. 177

On the other hand, where there is much diarrhoea it is not so serviceable as
morphia or opium, because it does not lessen peristaltic movement. It can be
pushed to a much greater extent than morphine without causing drowsiness,
dose employed is one-half to one grain in pill, given as often as needed.

Antipyrix in Chorea.

Additional contributions on this point will be found in the TJierapeut. Monats-
hefte, April, 1888, pp. 177 and 191, and May, 1888, p. 249. Though the cases
are few, the observers agree as to the benefit of the remedy. In a child of
eight, gr. viij have been used. One reporter has used a fifty per cent, solution
subcutaneously, beginning with half a syringeful and increasing to two in
twenty-four hours.

PaIXLESS TOOTH-DRAWINL.

Hexoque and Fredot, before the Soctete' de Biologie, of Paris, drew atten-
tion to a plausible and neat application of a physiological principle. An
atomized ether spray, directed on the region about the external auditory
meatus, will produce through the distribution of the trigeminus an anaesthesia
quite sufficient to annul the pain of drawing teeth. — Ther. Monatthefte,
March, 1888, p. 144.

To the usual cocaine solution, injected between gum and tooth, Martix
{Lyon Mhdieale, 1888, No. 1 ) has added antipyrin. The anaesthesia is as com-
plete and lasts longer, though slower in coming on. It has the additional
advantage of diminishing the amount of cocaine used and the risks in conse-
quence. The percentage of cocaine is four, of antipyrin forty, in distilled
water. Martin affirms of this mixture a quick influence over the pain of acute
periostitis.

Phexacetix — a New Axtipyretic.

This chemical product, brought to the attention of the profession a year
ago by Kast and Hixsberg (Centralb. f. med. Wiss., 1887, No. 9), has been
tested by a number of observers and seems to be of great promise. It is a
tasteless powder, almost insoluble in the usual solvents ; hence, is to be given
in capsule or placed on the tongue. The latter way is agreeable enough, even
in children, because it is absolutely tasteless. Given to a healthy individual,
in quantities of gr. xxx to gr. xlv in a day, absolutely no bad effect has been
noted (Rumpf, BtrL kl'ut. Wochenschr., June 4th, p. 457). Neither have
unpleasant symptoms accompanied its administration in disease. As an anti-
tic, Rumpf finds it absolutely reliable and without drawbacks. In doses
of gr. viij, and with half that quantity in children, he saw the temperature
untly fall from 3.6° to 5.4° F. Used as an analgesic, it showed itself decid-
edly useful. Rumpf prefers phenacetin to antipyrin and antifebrin, on acconnt
of its greater effectiveness and the absence of unpleasant after-effects.

A Novel Extexsiox of the Anesthetic Uses of Cocaixe.

E. Hurry Fexwick {Lamed, 1888, i. 871) discovered accidentally that
ine applied to the urethra relieved a patient of neuralgic pain of the face

178 PROGRESS OF MEDICAL SCIENCE.

and limbs. Experiments on frogs convinced him that this would generally
be the case with pains of this sort, but that more severe pains, as those of
carcinoma and inflammation, would probably be uninfluenced by it. The
clinical test in over 100 cases of neuralgic pain in various parts of the body
fully corroborated this, and the author reported several instances in which
facial neuralgia, wry neck, intercostal neuralgia, pain in the legs, etc., were
surprisingly relieved in a few seconds or minutes by a urethral injection of
twenty or thirty drops of a twenty per cent, solution of cocaine.

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLER, M.D., F.R.C.P. Lond.,

PR0FE8S0B OF CLINICAL MEDICINE IN THE UNIVER8ITY OF PENNSYLVANIA.

Assisted BY

J. P. Crozer Griffith, M.D., Walter Mendelson, M.D.,

ASSISTANT PHYSICIAN TO THE HOSPITAL OF THE PHYSICIAN TO TnE ROOSEVELT HOSPITAL, OUT-

UNIVERSITY OF PENNSYLVANIA. DOOB DEPARTMENT, NEW YORK.

On the Treatment of Typhoid.

A very suggestive and comprehensive clinical lecture of Ziemssen's on the
treatment of typhoid fever will be found in Centralblattf. gesnmmte Ther., March
and April, 1888. His remarks on diet and the temperature are especially in-
teresting. Nitrogenous matter should not be omitted from the diet any more
than in health, because Bauer and others have shown that it does not increase
the fever and is in great part absorbed ; while carbohydrates are especially
well taken by patients. Only liquid food is allowed, and especial care should
be taken throughout the sickness for changes in taste and consistence. Oat-
meal and barley gruels are recommended for continued use — many variations
may be given their taste by flavorings. Soups he also gives freely — but they
should be carefully strained and freed from any particles. Plain stock, with
or without the yolk of egg, meat extracts, meat juice, etc., are excellent. Milk
Ziemssen praises as a superior article, but limits the amount to one pint per
diem, warning against too great quantity. Raw beef-juice he uses as a routine
article, and warmly commends. It is pressed from the raw beef — keeps
twenty-four hours on ice and in porcelain, and shows six per cent, albumen ;
one drachm is given at a dose, and five or six teaspoonfuls in twenty- four
hours. Two drachms may be added to a pint of soup (which should not be
hotter than 147°) ; a small quantity of Liebig's beef extract improves the taste.
When the stomach rejects food an ice made with beef-juice is well borne. It
has the advantage over egg (alb.) that it does not create disgust in the patient.
To broths Ziemssen adds beef extract in very small quantity, both for taste
and stimulating effect on the nervous system. If eggs are given, three a day,
as a rule, are enough.

For the fever Ziemssen especially recommends the lukewarm bath gradu-

MEDICINE. 179

ally cooled. The patient siu in a bath of 87°-92°, and the water is kept in
constant motion and splashed continuously on the parts out of water. It is
to be cooled down about 10° by cold water poured on to the patient's feet.
The duration of the bath should be not under fifteen minutes, nor over
thirty. This form of bath is suited for most cases. The very cold bath
Ziemssen condemns as causing too great shock, but he does use as low a
temperature as 67°, being guided by the fever and nervous disturbance. A
warm bath Ziemssen has found very beneficial in the adynamic state. Of
the use of antipyretics, strange to say, Ziemssen says nothing, barely referring
to antipyrin as preferable to other antipyretics.

The Value of Salol Of Acute Rheumatism.

J. R. Bradford (Lancet, 1888, i. 1072) reports his experience with salol
in about sixteen cases of acute rheumatism, all of average severity, with
considerable fever. After detailing some of them, he concludes that, as an
antipyretic, salol is decidedly efficacious in rheumatic fever, but only after
three or four days, and when ten grains every hour are administered; and it
is not quite so reliable as salicylate of soda. To relieve the joint pains it is
decidedly inferior to salicylate of soda, both in certainty and in rapidity.
Relapses occurred as after the salicylate, but yielded to increased doses of the
drug. It produces the characteristic toxic symptoms of salicylic acid, though
to a less marked degree. That in some cases it was tolerated by the stomach
when salicylate of soda was not, is probably to be accounted for by the fact
that less of the active principle is contained in it, and the dose was, therefore,
proportionately smaller. The same fact explains the less degree of the other
toxic symptoms.

The author concludes that the efficacy of salol depends purely on the
contained salicylic acid, and that salicylate of soda is on every ground to
be preferred to it.

The Action- of Acids axd Axtipyrix in the Treatment of
Sick Headaches.

To Dr. Alexander Haig, of London, we owe some very valuable obser-
vations upon the relationship of various forms of megrim to the presence of
an excess of uric acid in the blood, and the effects of acids and alkalies upon
this condition. He has shown (British Medical Journal, January 14, 1888) that
during a headache uric acid is excreted in excess in the urine, and probably
also exists in excess in the blood ; and that as acids have the power of dimin-
ishing the excretion of uric acid, it is possible to relieve the cases of megrim
dependent on this condition of excess, by a large dose of some acid, as nitro-
hydrochloric. The action of antipyrin, now so largely used in the treatment
of megrim, Haig explains (British MtdicalJournal, May 12, 1888) by the fact
that the drug acts like an acid, and hence diminishes for the time the excre-
tion of uric acid. He found that a dose of twenty grains raised the acidity
of the urine within the first hour of taking it, and that the rise continued
and increased for five or six hours more. A drachm taken in three doses
caused a marked increase in the acidity of the twenty-four hours' urine, and
a decided fall in the uric acid excretion.

180 PROGRESS OF MEDICAL SCIENCE.

Salicylate of Sodium in Headache.

Little highly extols this drug in what he calls migrainous headache —
severe, accompanied by nausea and essentially neuralgic — though not typical
migraine (sick headaches). Up to October, 1885, he knew of no remedy with
a distinct influence on the paroxysm. Commencing then with the salicylate,
it has been his mainstay in treating a large number of cases, with " strikingly
beneficial" effect. In the discussion several gentlemen who had used the
remedy at Little's suggestion endorsed his claims, one man's experience count-
ing thirty cases.

R. — Sod. salicylat. gr. xx.

Effervesc. cit. caffeinae oij-

To be taken at the earliest premonition and repeated once or twice at two
hours' interval, if necessary. The caffeine makes it more palatable, and is, no
doubt, an adjuvant, although not the efficient agent, as a previous futile use
of it in some of the cases proved. — Dublin Med. Journ., June, 1888, p. 489.

Gastric Epilepsy.

Wynne {Dublin Journ. of Med. Sci., 1888, 384) reports a case of epilepsy
developing at seventeen years of age, and lasting six years. Some months
before the age of onset he had had an attack of scarlatina, and at the age of
three years he suffered from cerebro-spinal meningitis, which was followed
by violent general chorea. The epileptic attacks appeared nearly always to
be induced by the ingestion of some article of food which disagreed with him.
The attacks were very frequently preceded by nausea, giddiness and confusion
of mind, and were often followed by vomiting. The great majority took place
during or immediately after dinner, while still in the dining-room. Recovery
finally followed the prolonged use of the iodide and bromide of potash. It
was also found that the attacks could be abbreviated by pinching, slapping,
etc., or by anything which kept the attention of the patient excited. It
would seem very probable that the early meningitis and the chorea had
impaired the nutrition of the motor centres, and left them with a predispo-
sition to further disturbance under the influence of another exciting cause.
The author then discusses some of the remarks by various writers on the
subject, and lays stress on the importance of a dietary regimen in the treat-
ment of the disease.

Paramyoclonus Multiplex.

F. R. Fry {St. Louis Cour. Med., 1888, 487) makes a short review of the
characteristics of the cases which have been hitherto published, and reports
a new example of the disease. The patient, aged thirty, had always been well.
For some years she had been continuously engaged in running a sewing-
machine. The disease commenced about three months previously to the time
of examination, since which time the attacks became more and DION frequent,
and finally occurred once or oftener every day. The symptoms consisted
in a clonic spasm of the muscles of the thighs, and sometimes of the arms,
shoulders, abdomen, legs and those of respiration. The patient was unable

MEDICINE. 181

to restrain the movements, and the effort to do so only produced fatigue.
The motions were bo. violent that the feet tramped the floor with force, and
the body jerked about in the chair. The seizures lasted for a few minutes,
and repeated themselves frequently at intervals of a few minutes. A sharp
blow on the thighs would usually induce an attack. Twice she has had
attacks immediately on getting into a cold bed. They sometimes began and
ended with a few deep, sighing respirations. During three months of treat-
ment gradual but steady improvement took place; the drug having the most
■ being chloral, though hyoscy amine and antipyrin were not without benefit.

Treatment of Pleuritic Effusions.

FCrbrixger B'-rl. kiln. Wo'henschrift, 1888, Nos. 12-14), from careful obser-
vations in a series of twenty-five cases, established the following relations
between siphon action and aspiration (suction) in removing fluid from the
chest — first allowing what would run off by siphon action and then deter-
mining the amount that could be got beyond this by aspiration (in all cases
no forced exhaustion was used, and the total amounts obtained were only
moderate — Fiirbringer is no believer in strong suction nor does his instru-
ment admit of it).

In 11 cases the quantity secondarily removed by suction was less than
one-tenth of the whole amount.

In 10 cases from one-tenth to one-third of the whole amount.

In 4 cases from one-third to the whole amount.

Thus, on an average, in ten per cent, of the cases the siphon fails to remove
one-half the exudation, and in some of the cases the main part cannot be
obtained except by aspiration. In one of the cases the siphon obtained none,
but aspiration 3*xvij. On the other hand, in two cases of 3*lxx and 3"xxx,
the siphon exhausted the whole.

TO cases, in which the combined method was used, two-thirds left the
hospital without its repetition being necessary. In 10 of the remainder needing
a second removal, Fiirbringer tried siphonage alone, and found 6 of them so
tedious that even the attendants remarked their long stay, and repeated opera-
tions were necessary in these 6. Furbringer's conclusion is, that in a con-
siderable number of cases, suction (aspiration) is a factor in healing, to neglect
which is a "sin of omission."

Fiirbringer has constructed an instrument which allows both siphonage and
the vacuum. It is on the principle of the ordinary wash-bottle of the labora-
tory. The long glass tube is connected with the trocar by a yard long piece of
rubber tubing. The operator uses another piece of tubing fastened to the short
glass tube through which to suck. Three ounces of an antiseptic fluid are first
drawn into the flask. After the trocar has been plunged in and the bottle
connected with the canula, slight suction with the mouth exhausts the air in
the tube between bottle and canula, so that on turning the cock of the canula
the fluid flows by siphon action. After this ceases a little suction by the
mouth establishes a vacuum sufficient to reestablish the flow.

Rheumatic Pneumonia.

In a lectun- at St. Mary's Hospital Cheaple [Limrtt, 1888, i. 861) said that
he had always considered that pneumonia in the course of acute rheumatism

182 PROGRESS OF MEDICAL SCIENCE.

is of very rare occurrence, and a search through the recorded cases of the
hospital confirmed this opinion. In the summer of 1887, however, there were
26 cases of rheumatism in the hospital, in 6 of which extensive pneumonia
developed, preceded in 5 instances by pericarditis. These all exhibited a strong
resemblance to each other, and the author reports them in full. In remarking
upon them he states that in 4 cases the interval between the onset of the peri-
carditis and that of the pneumonia was six to seven days. In one instance it
could not be determined with accuracy, and in the instance in which no peri-
carditis was noted, it may have been present but undetected. In 4 of the 6
cases there was old-standing valvular disease, and in the other 2 it developed
during the attack. These cases of rheumatic pneumonia differ from ordinary
lobar pneumonia in certain important particulars. In every instance it was
the lower lobe of the left lung which was first involved, instead of the right,
as is ordinarily the case. In 3 cases there was later a similar affection of the
right. Cough and expectoration were entirely absent, and crepitation less
abundant than in most cases of ordinary pneumonia, and in the first case was
not detected at all. Finally, the temperature fell by lysis in all the O

These differences in the physical signs and symptoms indicate that the
morbid condition of the lung in rheumatic pneumonia differs in some way
from that of the ordinary form. This may be due in part to the presence of
organic heart disease, of pericarditis, and possibly of myocarditis, embarrass-
ing the heart's action and causing a rapid transudation of fibrin in a highly
fibrinogenous condition. But this throws no light upon the transfer of inci-
dence from the right lung to the left, and the author sees no explanation for
it. Again, there must have been some immediate exciting cause for this excep-
tional outbreak, since diseases of the heart are common enough in the course
of rheumatism. The most rational explanation is that during this summer the
weather was excessively hot, and the wards were ventilated with unusual free-
dom. Rheumatic patients are very susceptible to cold, and it is reasonable
to suppose that the chilling from strong currents of air streaming in from
windows and ventilators might easily determine the development of inflam-
mation of the pericardium, lung or pleura in the existing physical condition
of organs so favorable to its production.

A few useful, practical hints may be deduced. First, whenever pericarditis
or sudden rise of temperature, or persistence of high temperature, or acceler-
ation of respiration occurs in the course of rheumatism, make a careful physi-
cal examination of the chest behind as well as in front. Second, protect
rheumatic patients carefully from draughts. This may well be done by the
use of a canopy over the bed. Lastly, where pericarditis or pneumonia arises
in the course of rheumatic fever, avoid the use of such drugs as salicyla;
soda or aconite, which are marked cardiac depressants Employ, rather,
salicin or quinine, perhaps combined witli citrate of potash.

Tut: Tkeatment of Phthisis by Oxy< in and Ozonized Oxvui.n.

Ransome (Molicil Chronicle, 188S, viii. 37), after a course of experiments
in several cases of phthisis, concludes (1) that pure oxygen without any
admixture of air may be inhaled continuously for at least fifteen minutes
without the least harm resulting, without producing inflammation <»r even

MEDICI-NE. 183

irritation of the air-passages, and without increase of fever or even of pulse-
rate ; (S) that 2000 to 4000 cubic inches of pure ozonized oxygen may be
breathed not only without harm, but with apparent benefit in the cases in
which it was tried; (8) that ozone diminished the number of bacilli, and
sometimes the expectoration, and that the general condition of the patients
mproved.

Al FECTIONS OF THE HEART IN TABES DORSALIS.

Influenced by the statements which have been made, to the effect that dis-
eases of the heart, particularly of the aortic valves, were very liable to
occur in tabes, and were in some way connected with it, Groedel {Deutsche
med. Wochentchrift, 1888, 397) has during the last seven years examined his
cases with especial reference to this feature. In one hundred and eight cases
of this disease he found but four instances of valvular heart disease, and in
none of them was there reason to believe that it was at all dependent
on the tabes; and he concludes with Leyden that the occurrence of valvular
:is is purely accidental. He has never in this affection seen an instance
of a diastolic murmur produced by irregular muscular action, as Angel has
supposed. On the other hand, he has frequently noticed the occurrence
of weakness and frequency of the heart's action, small pulse, palpitation,
dyspnoea on exercise and sometimes, even, when at rest; but even these
are not characteristic of tabes, and are liable to occur in any form of chronic
disease accompanied by amemia or neurasthenia. There may be a sense of
oppression or of pressure in the region of the heart, which is probably to be
classified as an irregular form of girdle sensation. Leyden has recently re-
ported four cases of tabes in which there occurred peculiar attacks similar to
those of angina pectoris, and Vulpian has also recorded a similar case.
Groedel reports two such cases, as well as a third, in which, however, there
was also hypertrophy of the heart and nephritis. It is very possible, as Ley-
den believes, that these attacks are directly connected with the tabes, and are
neuralgic affections of the cardiac branches of the vagus; just as the gastric,
laryngeal and bronchial crises represent a similar disorder of other branches
of the same nerve.

The Connection between Diabetes Mellitus and Diseases of

the Heart.

JAOQUM Mayer, of Carlsbad {Zeitschr.f. klin. Med., 1888, xiv. 212; also
Brit. Med. Joum.. 1888, i. 949), says that the occurrence of attacks resembling
angina pectoris, both in the initial and the more advanced stages of diabetes,
has led him to make an examination of the physical condition of the heart
in a large number of cases under his care during the last nine years. The
whole number equals 380, of which 337 were in the first stage, and 43 in the
rod. The cases are further to be classified in three types, according to
their general appearance: 1. Pale, feeble, delicate, anxious-looking patients.

2. Vigorous, healthy-looking patients, with florid, animated countenances.

3. Obese patients, some of whom are ruddy, some pale and sallow.

In the beginning of the complaint examination of the heart and vessels
rarely shows any change due to the presence of sugar, or of an increased

184 PROGRESS OF MEDICAL SCIENCE.

amount of urea in the blood ; but later in the disease changes occur whose
nature depends on the type to which the patient belongs. In some c:
of the first type endocarditis sometimes develops; in others there are the
well-known symptoms of cardiac debility coming on suddenly without phys-
ical signs of change in the heart muscle or endocardium, and in still others
the organ becomes dilated, and gives rise to severe dyspnoea and delirium
cordis on the action of some exciting cause. In the majority of the cases
of the second type there arise after a variable time the general symptoms
and physical signs of idiopathic hypertrophy of the left ventricle. This
condition may persist for years without much systemic disturbance ; but
when the nutrition becomes impaired, the heart becomes relaxed and
dilated, and signs of cardiac debility appear. In a considerable number of
cases of diabetes cardiac hypertrophy and dilatation develop without there
being any morbid changes in other organs. This is due to the chemical
irritation of the heart by the sugar and by the increased amount of urea in
the blood. But the abnormal condition of the blood leads to changes in
the urine, and this again usually induces alterations in the structure of the
kidneys and disturbances of their functions, and it is in this latter way that
the hypertrophy and dilatation of the heart, so frequently found in dia-
betes, are generally produced. The author has examined the records of the
Pathological Institute of Berlin for the last thirty-two years and has found
that thirteen per cent, of the cases of diabetes had hypertrophy and dila-
tation of the heart. Changes in the vessels in this disease are probably sec-
ondary to the affection of the heart. It seems evident that it is the morbid
metabolism which is the active agent in producing the organic changes. As
regards treatment, it is clear that everything should be avoided which may
impair the action of the heart and kidneys, since organs which are in a state
of hyperactivity easily become diseased; and it is on this account that a
rigidly nitrogenous diet cannot, in all cases, be enforced.

The Treatment of the Chronic Diseases of the Heart Muscle.

After a very interesting discussion on this subject, Oertel ( Therap. Monatt-
hefte, 1888, 201) draws the following conclusions concerning his method of
treatment :

1. Only good results are obtained in the mountain resorts (Terraincurorte)
in the latter stages of fatty heart, where there is no evidence of sclerosis of
the coronary arteries, occurring usually in persons advanced in years, with
serous plethora, venous congestion and often oedema. These good results
consist in increase of the heart's strength, a regulating of its action, increase
of albuminous matter composing it, and often a decrease of its amount of
fat. There is also an increase of the general bodily powers.

2. There is further obtained by this method, in cases of valvular disease,
or of obstruction to the pulmonary circulation, an increase of the muscle sub-
stance of the heart, and the production of compensatory hypertrophy.

3. Extensive non-compensatory dilatation, resulting from diminished
strength of the heart muscle and increased intra-cardiac pressure, in not too
chronic valvular lesions in young people, is made to disappear.

I. ill. it is obtained the most complete possible adjustment between the

MEDICINE. 185

arterial and venous apparatus, together with increase of the quantity of
blood and of the pressure in the aortic system, and diminution of cyanosis
aii'l of oedema.

■"'. Diminution and complete disappearance of disturbances of the respira-
tory apparatus, especially of the rapidly developing dyspnoea and oppression
art- obtained.

gards the permanence of the good results produced through this
dietetic-mechanical treatment, time only can decide ; but the author has
patients in whom the restored compensation has lasted at least twelve years.

Lichtheim's conclusions, in his address delivered on the same occasion as
that of Oertel's {Ibid., 211), are as follows:

1. Oertel's method is a sovereign means of cure for those forms of chronic
heart disease whose genesis is due to intemperance in eating and drinking,
and to lack of bodily exercise.

2. In those diseases of the heart, on the other hand, due to the dilating
influences of immoderate bodily exercises, or other causes, this method is
of no value. Bodily exertion is only to be allowed in moderation and when
there is tolerable compensation, and it must never be allowed to produce
much dyspnoea. This class of cases is to be treated much more carefully than
are instances of real valvular disease.

3. The treatment with digitalis, strophanthus and caffeine remains the
principal one for disturbances of compensation. Where the use of drugs
fails, the dietetic method is also of no avail. Only in the removal of hydrosis
is Oertel's method of real assistance to the treatment with drugs, though it
can never take the place of the latter.

4. During the period of intact compensation the use of medicaments is
superfluous, and Oertel's method, used in moderation, finds its true field.

ENDOCARDITIS FROM PXEL'MOCOCCI.

Haush alter (Rerue de Med., 1888, 328) records an interesting case of
pneumonia in which there were no symptoms at all pointing to an affection
of the heart ; and in which the post-mortem examination failed to reveal any
important macroscopic change in it, except an almost invisible elevation at
the insertion of one of the mitral leaflets. Section of another part of one of
the mitral leaflets, however, showed, on microscopic examination, a mass of
characteristic pneumococci iu the centre of its thickness, and not reaching to
the surface. There being no superficial destruction of tissue, these must have
reached their seat by way of the capillaries supplying the leaflet. The pneu-
mococci lying enclosed in the tissue might act as foreign, irritating bodies, and
set up a sclerosing inflammation ; and, in fact, on the surface of the leaflet
over the focus of cocci there was a slight swelling, visible only with the
microscope, which was perhaps of this nature.

The author concludes: 1. That in the infectious diseases, the absence of
auscultatory signs during life, and of the visible lesions of ulcerative or ver-
rucose endocarditis after death, does not always signify that the valves have
not been attacked by the infectious germ. 2. That there perhaps exists a
variety of chronic endocarditis whose point of departure has been the presence,
at a certain time in the affected valve, of microorganisms pathogenic of an

186 PROGRESS OF MEDICAL SCIENCE.

infectious disease which was going on at the time. 3. That between the
occurrence of the acute malady and the appearance of the cardiac symptoms,
there may be a longer or shorter latent period, during which the attention of
the physician ought to be directed to the possibility of the development of
the cardiac disease.

The Diagnosis and Treatment of Gastric Ulcer.

In discussing Gerhardt's lecture on this subject (see this Journal for June,
1888) Guttmann (Deutsch. med. Wochenschr., 1888, 440) states his belief that
the determination of the amount of HC1 in the gastric secretion is of diagnostic
value between gastric ulcer and carcinoma. His somewhat extended experi-
ence shows that in the last condition the quantity is always below normal, or
entirely wanting; while the examination of ten cases of gastric ulcer always
revealed an excess of HC1 over the average amount normally present. For
treatment he, therefore, recommends the employment of such agents as bicar-
bonate of soda to neutralize the acid.

Sublimate Enteritis.

Frankel (Deutsch. med. Wochenschr., 1888, 443) calls renewed attention to
the fact which he announced two years ago, that the external use of the
bichloride of mercury in the treatment of wounds was capable of calling forth
a severe diphtheritic inflammation of the intestine, especially in debilitated
individuals. This is most apt to occur when those portions of the body most
capable of absorption are exposed ; as the peritoneum or the inner surface of
the uterus after parturition. The diphtheritic inflammation attacks the large
intestine, and only exceptionally the ileum also. He denies altogether the
claim of Sanger that calcareous infarcts in the kidneys are characteristic of
this sublimate enteritis ; since not only are they found in other conditions,
but Frankel has failed to discover them in any of the cases of this disease on
which he has made autopsies. He states further that other forms of mercury,
as well as the bichloride, are capable of producing the intestinal inflammation.

The Prognostic Significance of the Blood Pressure in Acute
Renal Disease.

Though every form of renal disease is usually attended by increased arte-
rial tension, Broadbent (Brit. Med. Journ., 1888, i. 840) has seen several
cases of cirrhosis of the kidney in which the tension was low. In acute renal
dropsy this is of more frequent occurrence, and it has always been associated
with an intractable character of the disease. In this condition the artery is
at first full between the beats, but the beat is short and easily arrested. This
corresponds to a time of temporary dilatation of the heart, but in the course
of a week or ten days the tension increases, showing that the heart has recov-
ered itself, and constituting a sign of favorable progress. The absence of this
increase may be due either to a persistent weakness of the heart, or to a
relaxation of the arterioles and capillaries ; both of which are of bad augury.
The author reports a case in full, in which the prognosis was given that the
disease would be of long duration, on account of the defective pulse-tension

MEDICINE. 187

and the weak blood-propulsion ; and the result showed that the prognosis
was correct. The imperfect development of the blood-pressure in these cases
is not the cause of the slow recovery, but is merely the indication of the con-
stitutional weakness which lies at the bottom of the delay. The development
or non-development of blood-tension is further a guide in treatment, since to
raise the tone of the circulation is to help to recovery.

Sai.ink Pusoatitsi ix the Treatment of Typhliti-.

C. W. Suckling (Brit. Med. Journ., 1888. i. 1112) reports two cases of
typhlitis treated by a mixture of sulphate of magnesia and sulphate of soda.
He believes that this plan of treatment is of great value in cases of typhlitis,
or peritonitis due to fecal retention. In moderate doses the salts do not cause
peristalsis, their action is quite painless and they wash away scybalous
masses. The abdomen should be frequently examined during their adminis-
tration, and stimulants administered if there is any evidence of accumulation
of fluid in the intestines. This sometimes occurs on account of the lack of
power of the bowel to expel the large amount of fluid which the saline
aperient produces.

Contributions to the Pathology of Chyluria.

In the Proceedings of the Medical Faculty of the Imperial University of
Japan (Centralbl. f. d. rned. Wtssensch., No. 17, 1888) Murata records obser-
vations made upon six cases of chyluria resulting from the presence of filaria.
He recommends that the search for the parasite be made during a whole night
or at least at midnight. Nearly all his patients passed bloody urine on rising
and chylous urine toward evening, the amount of fat in the urine being
greatly influenced by that taken as food. The embryo parasites may find
an exit from the body in a number of different ways, besides through the
urine; thus they have been found in the stools with chylous diarrhoea, in the
discharges from the ruptured skin of lymphoid scrotum, and suppurated
lymphatic glands, also in the tears, and in the blood from an haemoptysis, fin
every instance it is evidently rupture of the lymphatics which liberates the
filaria.] Murata made the original observation, too, that the kidney may be
the seat of the chyluria, for he found in the pelvis of one kidney a large
coagulum filled with filaria, while no other lesion of the lymphatics of the
urinary passages could be discovered. He concludes, as a general summary
of his observations, that the symptom chyluria is the result of rupture of a
lymphatic vessel in the urinary tract, resulting from the engorgement con-
sequent to thrombosis of the thoracic duct from occlusion by embryo filaria.

Grimm, from observations made upon the case of a patient who had lived
in Brazil for some time ( Virchow's Archiv, vol. iii. p. 341 ), arrived at much
the same conclusions as Murata regarding the cause of the symptom chyluria;
namely, that it is the result of rupture of some lymphatic vessel in the urinary
tract. Careful and systematic examinations of the urine, especially in rela-
tion to diet, lead to this result. He found that a diet rich in fat caused a
perceptible increase in the fat contained in the urine within an hour and a
half after ingestion. Also, that various heterogeneous substances reappeared

vol. 9C, so. 2.— Acorsr, 1888. 13

188 PROGRESS OF MEDICAL SCIENCE.

in the urine. Neither peptone, hemialbumose, nor sugar was ever found to
be present.

Adult Filaria Sanguinis Hominis.

It seems a little singular, considering how long the parasitic nature of chy-
luria has been recognized and how many cases have been carefully studied,
that so little is known of the life history of the filaria sanguinis hominis
which causes it. Indeed, the adult worm has rarely been seen, and those de-
scribed have been females. Prof. Bourne, of the Presidency College, Madras,
reports in the British Medical Journal of May 19, 1888, having received
two specimens of adult worms found in an amputated lymphoid scrotum of
an infected patient. One of these was a female, agreeing closely in appear-
ance with the figure given in Cobbold's work on parasites, published in 1879.

" The male specimen," he says, " is about an inch and a quarter long ; the
anterior extremity is wanting, but the caudal extremity is intact and presents
two spicules. The structure of these spicules will doubtless form a valuable
specific character. The spicule is broad at its proximal extremity, and
gradually tapers until it becomes capillary in character. About half way
down there is a lateral prominence, and when in situ the spicule is folded on
itself, so that the prominence forms the actual free extremity of the spicule,
while the broad end and the capillary end lie near to one another. It is in-
teresting to note that in this case, as in Lewis's case, the male and female
were in close contiguity."

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

81'RUF.ON TO THE PHILADELPHIA AND HERMAN HOSPITALS; CLINICAL PROFESSOR OF QENITO-l 111 N A K V
SURGERY IN THE UNIVERSITY OF PENNSYLVANIA.

1 >i-i n i t.ction of Surgical Instruments and Dressings.

\Us A.-RT) {Revue <te CMruri/ic, X<>. C, isxxi -hows that disinfection of sponges
and instruments by a five per cent, carbolic acid solution is unreliable,
many of the pathogenic organisms withstanding a soaking of from thirty to
forty-five minutes. Bichloride he concedes is more powerful, bat objection'
ahle in many cases from its chemical action ; for sponges it is to be preferred
!<• carbolic solutions. Flaming, if thorough, is efficacious, but again re-
stricted in its range of application. Boiling at 212° F. will destroy -
only If long continued. Steam at 230° F. destroys all microorganisms sub-
mitted to its action in thirty mitiu

Etenard has devised for the sterilisation of his instruments and dressings an
apparatus similar to that used by bacteriologists. He uses a cylindrical

copper baiter aboal an eighth fall of water; baskets containing the instra*

SURGERY. 189

ments, and provided with feet to raise them from the surface of the water are
put into the cylinder, a lid containing a manometer and a safety valve is
screwed in place, and by means of an alcohol lamp the water is raised to the
boiling temperature. The air in the cylinder passes off by a stop-cock in
the lid. which is then closed and the pressure is increased till it represents a
temperature of 230° F. One-half an hour's exposure is sufficient for absolute
disinfection. Sponges should not, of course, be subjected to this treatment,
nor for instruments should the temperature be allowed to exceed 245° F.

Renard concludes his somewhat elaborate article with the following propo-
sitions :

1. Disinfection by means of steam compressed at 230° F., as applied in the
apparatus described, is certain and practical.

Instruments or dressings submitted to this treatment for fifteen to twenty
minutes are absolutely disinfected.

3 The apparatus is very simple, not dangerous, and can be trusted to a
nurse.

4. Neither instruments nor dressings are in any way altered by a prolonged
treatment if the temperature does not exceed 230° F.

liucotm Membrane Grafts.

\V< >[.fler (Dcittsrh. Gesellsch. fiir Chirnrg., xvii. Kongress) reports some
cases of mucous membrane transplantation which were as successful in sequel
as Thiersch's more widely known transplantings of the epidermis. The
mucous membrane was cut into thin strips of an inch to an inch and a half
long and of a third of an inch broad. That taken from young persons grew
best. The wound should be three or four days old.

In three cases of impermeable urethral stricture, the cicatricial tissues
together with the urethra were excised. After three days the continuity of
the urethra was restored by transplanted flaps of mucous membrane, and a
catheter was left in the bladder to act as a mould for the new canal. The
results were highly satisfactory. In other parts of the body the procedure
was equally successful.

Removal of a Tumor of the Simnal Cord.

Gowers and Horsley read, before the Royal Medical and Chirur-
gical Society (June 12, 1888), the medical and surgical histories of a case
of removal of a tumor from the spinal cord. Paroxysmal agonizing pain
increased on motion, paraplegia, spasm of legs, foot and rectus clonus,
pain around the trunk and retention of urine, were the more gross features
of the ease on which Gowers founded his diagnosis. Horsley exposed the
spinal column from the third to the seventh dorsal vertebra, cut off the spi-
nous processes of the fourth, fifth and sixth ; made his way through the
lamina and ligamenta subflava, opened the dura mater in the middle line, and
exposed the cord. No abnormality being found, a portion of the third dorsal
vertebra was cut away, when the cord was found compressed by a tumor
of the dura mater; this was readily removed: the wound was closed, and
promptly healed by first intention. All pressure symptoms gradually disap-
peared ; the patient remains entirely well.

190 PROGRESS OF MEDICAL SCIENCE.

Laparotomy in Peritoneal Tuberculosis.

Kummel remarks [Archiv fur klin. Chirurgie, vol. xxxvii.) that whereas,
not very long ago, tuberculous peritonitis was only noticed by accident, as,
for example, when abdominal section was performed on account of supposed
ovarian disease or other abnormal abdominal conditions, yet now it is cor-
rectly diagnosticated and recognized as a local disease, as in tuberculosis of
bones and joints. It is also, like them, treated by operative measures. He
analyzes forty cases in which this condition was found, the patients ranging
in age from four to fifty-six years, but the majority between fifteen and
twenty. Most of the operations were based on false diagnoses. All but two
were women. In the two males the condition was noticed incidentally while
operating for ileus. Only in a few instances was the tuberculosis diagnosti-
cated and the operation undertaken for its relief. As a rule, these cases all
appeared to be cystic and consisted of collections of liquid between lymph
bands, more or less organized. In a smaller proportion the tuberculosis was
general. In no cases did the operation cause a hastening of the process, but,
on the contrary, it always seemed to have a distinct ameliorating and retard-
ing influence. He concludes that laparotomy may be regarded as a curative
as well as a palliative measure in the treatment of abdominal tuberculosis.

Fixation of a Movable Lobule of the Liver by Means of
Laparotomy.

Dr. E. A. Tscherning [Centralblatt fiir Chirurgie, No. 23) reports a case of
" hepatorrhaphy " for pain and disability attendant on the pressure of a large,
movable, constricted portion of the liver. The patient, aged thirty-six, previ-
ously at times a sufferer from icterus, noticed for five years a swelling on the
right side of the abdomen, gradually increasing in size, and attended with such
pain that she was incapacitated for her household duties; this pain being
subject to remissions and exacerbations, but never entirely leaving her, of a
darting, shooting character, relieved by rest in bed, but aggravated by motion.

On examination, a tumor was felt in the lower part of the abdomen, ex-
tending from the right lumbar region to somewhat within the nipple line, and
from the anterior superior spinous process of the ilium to the curvature of the
ribs. Percussion dulness of liver was continued into that of the tumor; the
connection between the two could not, however, be detected by manipulation.
Liver dulness extending to the fourth interspace in nipple line. Left lobe
moderately enlarged. Tumor smooth, irregular on surface, firm, without
pulsation, fremitus or friction sounds; free lateral movement; slight tender-
ness.

/» ■■/itnsis. — Hepatic tumor, possibly I liver constriction.

Opera/ion. — Incision from twelfth rib to a point somewhat anterior to the
anterior superior spinous process of ilium. Extraperitoneal exploration
showed sound kidneys and an Intraperitoneal tumor. Parietal peritoneum
opened, some prolapsed gut replaced, and the tumor readily drawn to the
wound. It was of firm consistency, grayish-white in color, and invested in a
fibrous capsule, Exploratory incision showed interstitially degenerated liver

tissue. Deep sutures stopped the bleeding from this incision. The tumor
was found to be a < ! portion of the liver, firmly attached to its right

si'KGKRY. 191

lobe by a broad pedicle. Fixation by means of two sutures sunk deeply into
tin.- rabstance of the tumor and fastened in the abdominal wall. To cause still
more extensive adhesions the peritoneal wound was packed with tampons
after Mikulicz's method; the posterior extraperitoneal portion of the wound
g sutured.
At first there were slight jaundice and albuminuria and some high tempera-
ture, the latter shortly subsiding. Patient was up in four weeks with a super-
ficial granulating wound. Two weeks later she left hospital ; wound healed.
'///// after rix month*. — Occasional moderate dragging pains, relieved
by a couple of hours rest. Feels well and attends to her housework.

'LECYSTOTOMY WITH LIGATION OF THE CYSTIC DUCT.

Dr. Ziei.ewicz {Centralblat fur Chi,-., May 31, 1888) believes the chief ob-
jection to simple cholecystotomy is, that it, as a rule, leaves a persistent fistula
and often lessens the nutrition. He says that the " ideal" operation, chole-
•tomy with suturing and return of the gall-bladder, has the danger of the
rupture of the line of suture due to over-distention of a still partially elastic
bladder. Besides this, if new stones form, the operation must be repeated.
It seems that cholecystectomy is less dangerous than cholecystotomy. He
cites one case in which he made an incision directly over the enlarged gall-
bladder and parallel with the median line. A double ligature was passed
around the cystic duct and this was cut between the two. The incision
too free and involved the liver substance, causing free hemorrhage, but this
was stopped by the use of iodoform and pressure. The bladder was then
freed as much as possible from the liver and stitched to the wound in the ab-
dominal wall. Then it was incised and there escaped some bile and a rough
mulberry-like calculus of the size of a walnut. The patient recovered. The
author claims this as the first successful case of ligature and section of the
cystic duct in a human being. The advantages of this method are :

1. Radical cure without a resulting biliary fistula and its consequences.
The gall-bladder is excluded from the organism as in exsection. Its secre-

. the product of its mucous membrane, diminishes in time because of the
cessation of the biliary flow, and especially after the cavity has become ob-
literated by newly formed granulations.

2. The operation is simple and less dangerous than cholecystectomy and
gives the same result.

-lOXEPHR'

Sacculated kidney is the title under which Kuster {Dettbch, m
Wochenschr., 1888, No. 19) discusses the symptomatology and surgical treat-
ment of hydronephrosis and pyonephrosis. These affections, regarded in the
text-books as distinct, are of the same nature; they may develop one from
the other, and cannot be distinguished from each other by either symptoms,
or physical signs.

er has operated on thirteen cases of sacculated kidney, eight being
completely and permanently cured. But two died, one from uraemia due to
disease of both kidneys, one some time after the operation from tuberculosis.

In regard to the etiology of cystonephrosis the author notes that in all

192 PROGRESS OF MEDICAL SCIENCE.

cases the onset of this affection is characterized by pus appearing now and
again in the urine. Pyelitis is the starting-point, which, causing a swelling of*
the mucous membrane, necessarily diminishes the lumen of the ureter and
makes it incapable of carrying off the very free secretion from the kidney.
Intra-renal pressure at once pushes the swollen mucous membrane, which is
somewhat movable, toward the obstructed outlet and forms a fold which still
further increases the trouble; as the swelling grows larger the orifice of the
ureter may become twisted, or the ureter itself pressed upon, making the ob-
struction absolute.

In making the diagnosis the tumor must first be proved to originate from
the kidney, then the operator must be assured of the nature of the affection
with which he has to deal. In regard to its origin, the enlargement lies
either in the kidney region, or can, if somewhat below it, be thrust back,
bimanual pressure from in front and laterally locating it close under the
twelfth rib. But slightly movable ; not affected by respiration, this latter
sign distinguishing it from a tumor of the liver or gall-bladder; also the fact
that, except in very great enlargement, there is a zone of percussion resonance
between this tumor and the liver.

A sacculated kidney may extend into the pelvis to such an extent that 00
superficial examination it would seem to rise from that cavity. A line of
tympanitic resonance can mostly be found separating the lower border of the
tumor from the true pelvis. An important point in distinguishing pelvic
tumors from this affection is the fact that the former give anteriorly, with very
few exceptions, dulness on percussion ; the latter toward the middle line of
the body are tympanitic. Especially significant is the course of the ascend-
ing and descending colon, which would necessarily be pushed forward or
forward and inward by kidney tumors; hence the lumbar region is dull on
percussion even anterior to the line of the axilla. The lumbar tympany is
Increased by all intraperitoneal tumors. Should the tumor be of such size
that its pressure has collapsed the colon a gaseous enema will so distend the
gut that its course can readily be detected.

From other kidney tumors cystic enlargement is to be distinguished by a
more or less distinct sense of fluctuation, which being obtained absolutely
diagnosticates either cystonephrosis or echinococcus cyst. Exploratory punc-
ture will distinguish between these affections, v. Bergmann's symptom of
an increased quantity of pus in the urine after firm pressure upon the cyst
was observed but once.

As to treatment: relief can be afforded only by an operation. The fact that
some secreting kidney timat is still left, the exhausted condition of the
sufferers, the high mortality of the operation all forbid a nephrectomy.
Nephrotomy is the only allowable operation, and the method employed has
a most important bearing on the subsequent course of the affection.

"jut <>/ operation. — Position of patient semi-prone, the affected lumbar
region being made to project as much as possible by a pillow placed beneath
the sound side. The incision begins at a point midway between the twelfth
rib and the brim of the pelvis at the outer border of the sacro-lumbalis
muscle, and is carried outward parallel to the pelvic brim for four to five
inches. The outer border of the latissimus dorsi and the three abdominal
muscles are then cut through; the lumbar fascia and the outer border of

SURGERY. 193

the quadratus lumborum being also somewhat incised. The thin trans-
versalis fascia is now exposed, and being opened brings the operator directly
to the capsule of the kidney. Bleeding is usually slight, but one or two
-els requiring attention. The posterior branch of the first or second
lumbar nerve, if found crossing the wound, may be cut. The capsule of the
kidney is freely exposed, loosened somewhat laterally, incised and its con-
tents drained off; the operation requiring about two minutes from the first
incision to the opening of the kidney. For the protection of the wound, the
sac should be drained by a canula, incised and its walls sewed to the skin
by threads passing through the lateral borders and both extremities of this
incision. By traction on these threads two assistants cause the cyst incision
to gape as widely as possible, the operator pressing the sac back with one
hand upon the abdomen while he passes half of his other hand into the
opening and carefully explores all parts of the sac. Septa are broken
d<>wn with the finger, or blunt-pointed knife. Bleeding is always very slight.
About the ureters an especially careful search must be made for stone.
None being detected, the ureter, if its opening can be found, should be ex-
plored by a flexible sound with a metallic tip.

A continuous catgut suture secures the cyst opening to the skin. The
cavity is thoroughly washed out, loosely filled with iodoform or thymol and
bandaged with a large quantity of absorbent material placed over the wound.
At first there is a very free discharge, necessitating frequent change of dress-
ings; this soon diminishes, a part of the urine passing through the ureter.
The fistula remains for some time, nor is it desirable that it should close
quickly, for if this takes place before the catarrhal inflammation of the sac
is cured this inflammation will continue indefinitely as a tedious, painful,
depressing affection, most difficult to benefit. Therefore, as soon as cicatricial
contraction begins the cyst should be washed out with astringents, nitrate of
silver (0.2 to 0.5 : 100) being especially well borne. If the external wound
- rapidly a drainage tube, the thickness of the finger, should be inserted,
and through it the washing continued until the urine passed from the bladder
is almost clear. It must be borne in mind that there will be a slight precipi-
tate of silver chloride if the nitrate has been used as a wash. The urine
being clear the tube is gradually diminished in size, finally removed and
the opening quickly closes. In this connection incision is proposed as a
treatment for obstinate suppurative pyelitis.

AN Kxi'ERlMENTAL CONTRIBUTION TO INTESTINAL SURGERY.

Senn, of Milwaukee, concludes, in the June number, 1887, of The Annals
of Surgery, a series of papers on abdominal surgery, remarkable for their
originality and practical suggestions. His experiments were made on cats
aud dogs, mainly the latter, and had in view especially the treatment of
intestinal obstruction. Among the conclusions founded upon the results of
his experiments are the following:

Traumatic stenosis from partial enterectomy, and longitudinal suturing of
the wound, becomes a source of danger from obstruction, or perforation, in
all cases where the lumen of the bowel is reduced more than one-half in size.

Longitudinal suturing of wounds on the mesenteric side of the iut

194 PROGRESS OF MEDICAL SCIENCE.

should never be practised, as such a procedure is invariably followed by gan-
grene and perforation by intercepting the vascular supply to the portion of
bowel which corresponds to the mesenteric defect.

The immediate cause of gangrene in circular constriction of a loop of
intestine, is due to obstruction of the venous circulation, and takes place first,
in the majority of cases, at a point most remote from the cause of obstruction.
On the convex surface of the bowel a defect an inch in width, from injury or
operation, can be closed by transverse suturing without causing obstruction
by flexion. In such cases the stenosis is subsequently corrected by a com-
pensating bulging, or dilatation of the mesenteric side of the bowel.

Closing a wound of such dimensions on the mesenteric side of the bowel
by transverse suturing, may give rise to intestinal obstruction by flexion, and
to gangrene and perforation by seriously impairing the arterial supply to, and
venous return from, the portion of the bowel corresponding with the mesen-
teric defect. Accumulation of intestinal contents above the seat of invagi-
nation, is one of the most important factors which prevents spontaneous
reduction, and which determines gangrene of the intussusceptum and perfo-
ration of the bowel. Spontaneous disinvagination is not more frequent in
ascending than descending invagination. The immediate or direct cause of
gangrene of the intussusceptum is obstruction to the return of venous blood
by constriction at the neck of intussuscipiens.

Ileo-caecal invagination, when recent, can frequently be reduced by disten-
tion of the colon and rectum with water, but this method of reduction must
be practised with the greatest caution and gentleness, as over-distention of
the colon and rectum is productive of multiple longitudinal lacerations of the
peritoneal coat, an accident which is followed by the gravest consequences.
The competency of the ileo-caecal valve can only be overcome by over-disten-
tion of the caecum, and is effected by a mechanical separation of the margins
of the valve, consequently it is imprudent to attempt the treatment of intes-
tinal obstruction beyond the ileo-caecal region by injections per rectum. In
cases of extensive intestinal resection, the remaining portion of the intestinal
tract undergoes compensatory hypertrophy, which microscopically is apparent
by thickening of the intestinal coats and increased vascularization. Physio-
logical exclusion of an extensive portion of the intestinal tract does not

impair digestion, absorption and nutrition, as seriously as the removal of a
similar portion by resection.

i] accumulation does not take place in the excluded portion of the

Intestinal canal.
The excluded portion of the bowel undergoes progressive atrophy.
A modification of Jobert's invagination suture by lining the intussusceptum

with a thin flexible rubber ring, and the substitution of catgut for silk nri

is preferable to circular enterorrhaphy by the Czerny-Lerabert suture.
The line of suturing, or neck of intussuscipiens, should be covered by a

flap or graft of omentum in all cases of circular resection, as this procedure

furnishes an additional protection against perforation.

In circular enterorrhaphy the continuity of the peritoneal surface of the

ends of the liowel to he united should he procured where the mesentery is

detached by uniting the peritoneum with a fine catgut suture before the

SURGERY. 195

bowel is sutured, as this modification of the ordinary method furnishes a
irity against perforation on the mesenteric side.

In cases of complete division of an intestine, if it is deemed advisable
n«>t to resort to circular enterorrhaphy, one or both ends of the bowel should
be closed by invagination to the depth of an inch, and three stitches of the
continue'! suture embracing ouly the peritoneal and muscular coats.

The formation of a fistulous communication between the bowel above and
below the seat of obstruction should take the place of resection and circular
enterorrhaphy in all cases where it is impossible or impracticable to remove
the cause of obstruction, or where after excision it would be impossible to
re the continuity of the intestinal canal by suturing, or where the patho-
logical conditions which give rise to the obstruction do not constitute an
intrinsic source of danger.

The formation of an artificial anus in the treatment of intestinal obstruc-
tion should only be practised in cases where the continuity of the intestinal
canal cannot be restored by making an intestinal anastomosis.

ro-enterostomy, jejuno ileostomy and ileo-ileostomy should always be
made by lateral apposition with partially or completely decalcified perforated
bone plates.

In making an intestinal anastomosis for obstruction in the caecum, or colon,
the communication above and below the seat of obstruction can be established
by lateral apposition with perforated approximation plates, or by lateral im-
plantation of the ileum into the colon or rectum.

An ileo-colostomy or ileo-rectostomy by approximation with decalcified,
perforated bone plates, or by lateral implantation should be done in all cases
of irreducible ileo-csecal invagination, where the local signs do not indicate
the existence of gangrene or impending perforation.

In all cases of impending gangrene or perforation, the invaginated portion
should be excised, both ends of the bowel permanently closed and the con-
tinuity of the intestinal canal restored by making ileo-colostomy or ileo-
omy.

The restoration of the continuity of the intestinal canal by perforated
approximation plates, or by lateral implantation, should be resorted to in all
cases in which circular enterorrhaphy is impossible, on account of the differ-
ence in size of the lumina of the two ends of the bowel.

In cases of multiple gunshot wounds of the intestines involving the lateral
or convex side of the bowel, the formation of intestinal anastomosis by per-
forated decalcified bone plates should be preferred to suturing, as this pro-
cedure is equally, if not more, safe, and requires less time.

Definitive healing of the intestinal wound is only initiated after the forma-
tion of a network of new vessels in the product of tissue proliferation from
the approximated serous surfaces. Under favorable circumstances quite firm
adhesions are formed within the peritoneal surfaces in six to twelve hours
which effectually resist the pressure from within outward.

Scarification of the peritoneum at the seat of coaptation hastens the forma-
tion of adhesions, and the definitive healing of the intestinal wound.

Omental grafts, from one to two inches in width and sufficiently long to
encircle the bowel completely, retain their vitality and become firmly ad-

196 PROGRESS OF MEDICAL SCIENCE.

herent iu from twelve to eighteen hours, and are freely supplied with blood-
vessels in from eighteen to forty-eight hours.

Omental transplantation, or omental grafting, should be done in every
circular resection, or suturing of large wounds of the stomach or intestines,
as this procedure favors healing of the visceral wound, and affords an addi-
tional protection against perforation.

The omental grafts used by Senn were from one and a half to two inches
wide and long enough to encircle the bowel completely ; the free ends were
made to project somewhat beyond the mesenteric attachment, and fixed by
two fine catgut sutures, each of which embraced the corresponding angles of
the graft and the mesentery, and was placed in the direction of the mesenteric
vessels.

In preparing these grafts, they were, as soon as cut from the omentum,
put in (1 : 2000) corrosive sublimate solution, and kept at body heat till the
operator was ready to place them, when they were carefully dried between
gauze, or sponges wrung out of the same solution in which they had been
lying. The peritoneum was then scarified with a fine needle, to the point
of producing a very slight oozing, and the graft placed in position. Senn
advises that, after suturing, a strip of omentum should be laid over large
wounds of the stomach, or intestines, and kept in place by a few catgut
sutures. These grafts should also be used in covering large stumps after
ovariotomy, or hysterectomy if the pedicle be left in the abdomen.

The Technique of Colotomy.

The obvious disadvantages of colotomy, as usually performed, are cited by
Maydl (Centralblatt fur Chirurg., 1888, No. 24) as the consideration which
led him to devise the operation which he describes. He opens the peritoneal
cavity by Littre's incision, and draws a loop of intestine forward till its
mesenteric attachment lies in the abdominal wound. Through a slit in the
mesentery close to the gut is inserted a hard rubber cylinder wrapped in iodo-
form gauze — a goose-quill will answer, if hard rubber be not obtainable. This
prevents the retraction of the intestinal flexure. By means of a row of sutures
placed on each side of the prolapsed gut, including the serous and muscular
coats, the two limbs of the flexure, in so far as they lie in the abdominal
wound, are stitched together beneath the hard rubber support. If the pro-
lapsed gut is to be opened immediately, it is stitched to the parietal peritoneum
of the abdominal incision and the latter protected by iodoform collodion. If
the incision of the bowel is to be delayed, the latter is not stitched to the
peritoneum but surrounded by iodoform gauze packed in beneath the rubber
support, the operation being completed in four or six days.

If the artificial anus is to be permanent a transverse opening, Including
one-third of the periphery of the bowel, is made by the thermo-cautery,
drainage tubes are inserted into the two presenting luinina, and the intestine
is carefully washed out. If all goes well the gut is entirely cn1 through in
two or three weeks, the rubber support serving well as a base upon which this
division can be effected. A few sutures will serve to secure the cut end to the
skin. If the direction of the muscular fibres has been regarded in making the

SURGERY. 197

abdominal incision, the patient is provided with such a good sphincter that a
large drainage tube is required to keep the opening patulous. Should only a
temporary artificial anus be designed, a longitudinal opening must be made
into the intestinal loop. When it is desired to close this opening the rubber
support is taken away, the bowel retracted by the mesentery, and the opening
spontaneously closed ; or, if the cicatricial adhesions be too strong to allow of
this, the bowel must be freed by the knife, sutured and returned to its proper
cavity.

Laiknstkin [toe. '-it.) accomplishes the same result as does Maydl, by
suturing together first the skin and peritoneum of his abdominal incision,
then drawing out a loop of intestine and closing his parietal wound by sutures
passing through the mescolon of the prolapsed gut, which is thus fastened in
the abdominal incision ; next the serosa of each limb of the prolapsed loop
is stitched through its entire circumference to the parietal peritoneum.

The Operative Treatment of Prolapsed Rectum.

Mikulicz {Deutsch. Gesellch. fiir Chirurg., xvii. Kong.) advises circular
resection as the best means of treating prolapse of the rectum, or prolapsed
invagination of the colon. In one case two and a half feet of the prolapsed
colon were resected, the patient making a good recovery. The patient is
placed in the lithotomy position. Two strong threads are passed through
the extremity of the prolapse and looped, serving for fixation. Irrigation
through the operation with antiseptic solution. Transverse incision of the
anterior portion of the intussuscipiens, going carefully through its thickness
and checking all bleeding. When the serosa is cut through, exposing the
serosa of the intussusceptum, the two serous membranes are stitched together
by a circle of fine sutures, thus closing all communication with the peritoneal
cavity. Just beyond the sutures the anterior part of the intussusceptum is
also cut through. The cut ends of the gut are now sutured to each other,
to the entire extent of the incision, by silk threads, including all the coats,
the threads being left long that they may serve to steady the bowel for the
completion of the operation. Finally, the remaining periphery of the two
intestinal lumina is secured, the numerous mesenteric vessels tied and the
union of the gut completed by the deep sutures. The line of suture is dusted
with iodoform. The long ends of the thread cut away, and what remains of
the prolapse is replaced within the anus. No drainage tube, no bandage.
Opium for eight days.

Suprapubic Cystotomy.

Eioenbrodt exhaustively considers the high operation on the bladder in
Deutsche Zeitschrift fur Chirurg., Bd. 28, 1 and 2 Hft., founding his conclu-
sions in great measure upon the thirty-eight cases operated on by Trendelen-
berg. Inflation of the rectum by the rubber bag is not advised, as the
peritoneum is readily avoided without such a procedure ; and that the latter
is not devoid of danger is proven by rupture and gangrene of the rectum
having followed its use ; in children, the bladder has been thrust to one side,
and in one case (St. Germain) the rectum presenting at the wound was,

198 PROGRESS OF MEDICAL SCIENCE.

together with the rubber bag, incised. When the suprapubic percussion
dulness of the full bladder can be recognized, no more fluid need be injected.
Over-distention is never necessary, nor previous treatment of cystitis, or
contracted bladder. The incision should be transverse; if extensive, slightly
convex downward, so that the extremities may correspond in direction with
the inguinal canal. On reaching the deep fascia and abdominal muscles, it is
most important to continue the operation as close to the pubic bone as pos-
sible, operating as though the object in view were the cutting away of the soft
parts from the upper and posterior portion of the symphysis. Trendelenberg,
by pressing with the fingers of his left hand against the sheath of the exposed
muscles, so stretches their attachments to the bone that a touch of the knife
them, and the danger of wounding the deeper lying soft parts is avoided.
A few muscular fibres of the pyramidales are divided, but the two recti are
not wounded.

The extent to which the fasciae and tendons are separated from the pubis,
depends upon the room required for subsequent manipulations. For the
extraction of an ordinary stone, an incision one and a quarter to one and
three-quarters inches in extent is sufficient. For tumor operations, or the
removal of very large stones, two and a half to three and a quarter inchc-
will be required, and both recti will be completely separated from the pelvis.
The fasciae and tendons having been cut from the pubes, the praevesical
cellular tissue is exposed, usually containing much fat. The knife must now
be laid aside, the second and third fingers of the left hand thrust in the prae-
vesical space, dorsal aspect to the bone ; the index and middle finger pressed
down well behind the symphysis till the region of the neck of the bladder is
reached, then bending the fingers, all the soft tissues lying anterior to the
bladder, especially the peritoneal fold, are drawn carefully upward ; the
bladder is now exposed, and can be safely incised, the fingers of the left hand
readily keeping the peritoneum out of the way. Tenacula are by this pro-
cedure unnecessary. If a very large incision into the bladder is required, the
peritoneum can readily be separated from that viscus for a considerable extent
with the fingers. In the manner described, even a bladder which has not
been injected is, in a few minutes, exposed and safely opened. Elevation of
thf pelvis greatly simplifies the operation, and in this position the patient
should always be placed.

Alter the completion of the operation, the bladder is thoroughly washed
out with a weak sublimate solution (1 : 3000 to 5000), a T-formed drainage
tube is placed in the bladder", carried over the symphysis, through the central
portion of the external wound ; the extremities of the superficial incision are
closed l>y a fewMitures passed through the skin, and iodoform gauze is loosely
packed in the open wound about the drainage tube. If the superficial incision
baa been extensive, drainage should be provided for at both extremities of
the wound.

1 1 a very large bladder incision has been made, a fewsutures may be in-
to leaMB the size of the wound, but complete closure by suture i< not yU jus-
tified by statistics. Batoring of the bladder with loose antiseptic packing of
the parietal wound, as advised by Kraske, Ultzmann and Mikulicz, is yet
mbjudtee.

SIRGERY. 199

Trendelenberg removes his drainage tube in from one to two weeks ; in
uncomplicated cases three to four weeks sufficed for a complete cure.

In cases of marked cystitis or pyelitis with alkaline urine a long-standing
fistula results, lasting, at times, if the condition of the urine be unchanged,
for life.

In Trendelenberg's cases there was no instance of urine infiltration or cel-
lulitis. In one case only was there burrowing of pus — the patient, a feeble
old man, dying of exhaustion thirteen weeks after the operation.

Of Trendelenberg's 38 patients 7 died in the course of treatment No
death can be ascribed directly to the operation.

3 perished of intercurrent disease more than one month after the oper-
ation, 2 of carcinoma (four and five days after the operation respectively), 1
of delirium tremens (twelve months after operation), and 1 of burrowing of
pus and profuse suppuration (two months after operation).

Against Konig's dictum, " The perineal incision must remain the natural
operation for the lighter cases, the more dangerous high operation being
reserved for the severe cases," the author contends that before operation it is
often impossible to tell how difficult the case may be, and shows by reference
to Trendelenberg's cases several instances in which history and examination
would have proven the case amenable to the median operation. The conditions
on opening, however, proved that none but the high incision could have
carried the patients safely through. All of Trendelenberg's uncomplicated
stone cases made a safe and rapid recovery ; and Assendeft, who has done
the high operation 102 times, lost but 2 patients, 1 from causes not connected
with the operation. All of his patients were young.

The high operation takes its place as beyond all other procedures in the
treatment of diseases of the bladder walls. All of Trendelenberg's tumor
cases were carcinomatous. If such tumors were promptly recognized and
treated, a relatively good prognosis could undoubtedly be given. An early
;>tom is slight but frequent admixture of blood with the urine, often not
observed because not accompanied by marked pain. Such bleeding, having
no obvious cause, should always suggest a bladder tumor, and lead the physi-
cian to make a most thorough and patient search for confirmation of the
diagnosis. If this necessitates an operation, the high incision should be
made at once, when, on confirmation, the operator can proceed directly to ex-
tirpation. This should be accomplished with scissors and sharp spoon, or by
excision of a part of the bladder wall ; bleeding being stopped by cautery.

Tubercle of the bladder gives rise to symptoms much like those of tumor,
and can often be diagnosed only by visual inspection after opening the
bladder. The high operation alone enables the surgeon to do this satisfac-
torily and undertake the radical extirpation of the diseased areas.

Finally, the high operation is commended as most suitable for posterior
catheterization, when, through traumatic stricture with great periurethral in-
flammation and cicatrization, or false passage with infiltration, or rupture of
the urethra, the ordinary means of procedure (ordinary catheterization, the
median operation, etc.) are no longer available.

200 PROGRESS OF MEDICAL SCIENCE.

OTOLOGY.

UNDER THE CHARGE OF

CHARLES H. BURNETT, M.D.,

PBOFEWOR Or OTOLOGT IN THE PHILADELPHIA POLYCLINIC AND COLLEGE FOB GRADUATES IN MEDICINE, ETC.

Abscess of the Cerebellum from Ear-disease.

Dr. J. Orne Green {Boston Medical and Surgical Journal, May 31, 1888)
reports a case of the above named disease occurring in a man, thirty-six years
old, who had been kicked in the temporal region by ahorse, fifteen years pre-
vious to his entrance into the Boston City Hospital, March, 1888. An otor-
rhcea had existed in the right ear since the injury on the temple. Within
the five months previous to admission he complained of headache, especially
in the right temporal region ; latterly he had vomited more or less without
apparent cause, and chiefly at night. Intellect clear, appetite good, bowels
not constipated. Examination revealed right facial paresis and otorrhea.
In four days the facial paresis disappeared without treatment.

Dr. Green found the meatus filled with polypoid growths, which were re-
moved under ether. Carious bone was detected in the posterior and upper part
of the tympanic cavity. The operation gave great relief, and the headache
and nausea ceased entirely for two or three days. The polypoid stump was
treated with spirits of wine, and the ear kept clean by antiseptic syringing.

The tuning-fork on the vertex was heard entirely in the right ear (the
affected one). The headache and occasional vomiting soon returned, and up
to time of death were intermittent, continuing for twenty-four or forty-eight
hours, then ceasing, to return again after one or two days. Slight momentary
delirium once or twice before death. Condition mostly somnolent. Sitting
up immediately caused great vertigo, and if this position was maintained,
vomiting ensued. Pain always referred to right side; right pupil somewhat
sluggish, and during the last week of life there was marked constipation.
The pain was not severe enough to require opiates, and no internal medica-
tion was given excepting calomel to overcome constipation. Twenty-four
hours before death there was mild delirium, with some screaming, as if from
pain, then unconsciousness, and within a half hour thereafter a quiet death.
The most continuous pain and most frequent vomiting occurred during those
days when the pulse was lowest. The temperature was normal throughout;
the pulse varied from 85 to 52.

The poffanerftSM examination revealed an ahscess of the cerebellum oppo-
site the foramen for the seventh nerve, on the vertical portion of the temporal
bone. The abscess, the size of an English walnut, contained greenish, otlen-
sive pus. Behind the tympanic cavity in the substance of the petrous bone,
opposite to the abscess, was a earious region. The traheculse of the mastoid
cells hud disappeared, and the cavity was filled with a soft, grayish, cheesy
material, with a foul odor.

The diagnosis was: Acute, eireumscrihed internal and external pachy-

OTOLOGY. 201

meningitis; acute, circumscribed leptomeningitis; abscess of the cerebellum ;
flattening of the convolutions of the brain ; dryness of the pia ; chronic middle
ear catarrh; necrosis of the mastoid cells and of the petrous portion of the
temporal bone.

Abscess of the cerebellum was not diagnosticated during life, as pain was
referred chiefly to the temporal and parietal regions. Furthermore, disease of
the posterior surface of the petrous bone, being less common than caries of
the upper surface, the former condition was not suspected. The easily excited
and great vertigo, however, pointed toward cerebellar disease rather than to
disease of the cerebrum. The case shows how slight the symptoms may be
in a case of abscess of the brain. »

Dr. Green says: " The possibility of evacuating, draining and healing an
abscess of the cerebellum has not, I believe, yet been demonstrated, although
a number of successful operations on the cerebrum have been reported. The
cerebellar operation offers unusual difficulties in that it is either necessary to
enter the skull below the superior curved line of the occiput in order to avoid
the large sinuses, or else to pass through the tentorium from above, with the
risk of imperfect drainage."

I.KUCOCYTH.flMlA, PRECEDED BY DEAFNESS AND FACIAL PARALYSIS.

A man, tifty-eight years old, had been in good health for fifteen years,
when he suddenly became deaf, especially in the left ear, and facial paralysis
appeared on the left side. The appearance of the ear was normal. Electric
treatment was painful and benefited but little, though it was conducted for
several weeks. Most relief was obtained from douching the face with warm
water and from poultices. The paralysis disappeared at last. Sleeplessness
and debility continued; also stiffness and sensitiveness of the previously
paralyzed facial muscles. Some acute symptoms set in, viz., painful cramp
in the calf of the leg, the lower extremities "going to sleep," sensation of ten-
sion and restlessness of the legs, etc., with increase of general weakness.
About this time there was discovered in the region of the umbilicus, beneath
the skin, five or six insensible tumors, the size of hazel nuts; similar
tumors had formed within a few months, in the lumbar region, but had not
been noticed by the patient. The liver and spleen were enlarged, but now
increased in size. With increasing weakness, severe pains at each movement
and further development of tumors, the breath became fetid, and the lym-
phatic glands in the neck increased in size, until they formed a large, com-
posite mass. One of the tumors removed from the abdomen was shown to
be a lymphadenoma. Examination of the blood exhibited forty-two white
blood cells in one field of the microscope. Death occurred six months after
the facial paralysis first appeared. There was no post-mortem examination.
(Gei.i.e, Revue Mensue/le de Laryngologie, No. 12, 18>7. i

202 PROGRESS OF MEDICAL SCIENCE,

DERMATOLOGY.

UNDER THE CHARGE OF

LOUIS A. DUHRING, M.D.,

PROFESSOR OF DERMATOLOGY IN THE UNIVER8ITY Or PENNSYLVANIA.

AND

HENRY W. STELWAGON, M.D.,

PHYSICIAN TO THE PHILADELPHIA DISPENSARY FOR SKIN HUIM

On a Peculiar Eruption of Comedones in Children.

Colcott Fox describes (Lancet, April 7, 1888) the features of a peculiar
condition occurring in children, apparently similar to the comedones of
adolescence. Instead of appearing scattered and with no relationship to
season as in the ordinary comedones after puberty, the disease showed a
marked tendency to occur in aggregations, on certain parts, and at certain
seasons. The lesion itself is undistinguishable from the comedo of the adult.
They usually make their first appearance on the forehead close to the scalp,
over the region of the eyebrows, and then tend to join and form a continuous
band. Scarcely a gland duct in the involved area escapes. There is also a
tendency for the same formation to encroach upon the scalp, and also down
the sides of the temples, in a strip, to the angle of the jaw. Their appearance
may be gradual or sudden, at times appearing and disappearing in the most
wonderful manner.

The disease is noted mainly in the spring and early summer; it tends
to disappear in the winter season, in some instances recurring the following
spring. It seems, with some exceptions, limited to children between the ages
of five and nine, and is, moreover, commonly seen in children's hospitals.
Inflammation about the plugs, although usually slight and secondary, may
occur, and give rise to the ordinary lesion of acne. Several children in one
family are often concurrently affected. The disease does not attack the
parents and other adults living with the affected children. Although a num-
ber of the patients attended school while affected, no evidence of communica-
tion to other scholars was traceable. In the thirty-eight cases in which the
sex was recorded, there were twenty-eight males. The eruption does not
appear to be dependent upon any condition of the general health. It i-,
moreover, seen in about the same frequency in the light and dark, and in the
delicate and robust. The plugs are apparently formed from the epithelial
lining of the follicles, and not from sebum as in the comedones of later life.

Investigation as to a parasitic cause developed nothing positive. In respect
to treatment the results are satisfactory. The same measures as usually cm-
ployed in cases of comedones in adults are to be advised.

Et] lOBGDI in OHBOVXO !■:< zi-.m a.

A favorable report is made ( Therapeutic Qazcttrt .lime, 1SSS) by M. Schmi i /
of the treatment of two obstinate cases of chrome ee/ema by means of appli-

DERMATOLOGY. 203

>na of resorcin. The remedy was employed as a solution in glycerin —
a half ounce of the former to four ounces of the latter. The patients were
young children, the disease chronic, and more or less general. The affected
parts were painted twice daily with the above solution, improvement there-
after being steady and continuous.

The Ointment of the Nitrate of Mercury as an Abortifacient
of Boils and Felons.

Kenner states [Medical and Surgical Reporter, April 14, 1888) that boils
and felons may be frequently aborted by applications of citrine ointment,
if treatment is instituted before positive suppuration occurs. The ointment
is applied in a thick layer, as a plaster, and allowed to remain on twenty-four
hours, at the end of which time further treatment is, as a rule, unnecessary.
The application is not painful, for the first several hours giving rise to a
peculiar drawing sensation, followed by complete cessation of pain and
tenderness.

On Lupus.

From an exhaustive paper {British Medical Journal, January 7, 14 and 21,
1888) on lupus by Hutchinson, the following observations, for the most part
in the author's language, may be said to express the substance of the views
presented : Many facts as to the cause of lupus— such, for instance, as its
frequently beginning after slight injuries to the part — would suggest the belief
that a stage of congestion and cell-effusion, undistinguished from common
inflammation, usually precedes for a short period the characteristic growth.

There are, further, no facts whatever which would support a belief that
lupus ever takes its origin from contagion.

Among the qualifying or descriptive adjectives which have been used for
lupus, that of "serpiginosus" can well be spared, as it is the very essence of
the disease to be serpiginous, and if any form of new growth or inflammatory
action were shown to be not so, it would certainly de facto lose all claim to
rank with the lupus family.

Its manner of spreading, moreover, proves that lupus action is attended by
the production in the part of elements which are infective to those with which
they are in contact — infection by continuity. Not infrequently, also, new
foci of disease appear which are not continuous with the original patch —
infection by contiguity — the infective material spreading probably either in
the perivascular spaces or along the lymphatic channels.

An absence of tendency to infect the lymphatic glands must be noted in all
forms of lupus, and with it also an absence of tendency to travel deeply or to
involve parts other than the skin. It is in the main a disease of exposed
parts, the face and the extremities being its most frequent sites ; and the more
protected the part, as regards warmth, the less is it likely to be the seat of the
disease.

As to the influence of age, it may be stated that the younger the patient
the greater is the probability that the disease will inflame and ulcerate, and the
greater by very far the risk that its infective material will become diffused,
and its manifestations multiple and distant.

TOL. 96, HO. 2.— ACOVST, 1888. 14

204 PROGRESS OF MEDICAL SCIENCE.

Although statistics from the author's personal observation showed but a
small percentage of the presence of other symptoms of scrofula, the opinion
is nevertheless expressed that lupus is in very many instances a scrofu-
lous disease ; but that in most instances the tendency to disease of this
type having begun in the skin restricts itself to it, and shows little or no
tendency to attack internal organs. There is also another peculiarity of
health which is of much importance in predisposing to certain forms of lupus
— the proclivity to chilblains. This concerns the erythematous form more
than common lupus ; but it is not without influence as regards the latter.

In discussing the histology of the lupus family the conclusion is given that
neither lupus erythematosus nor lupus vulgaris is a disease of any special
structure in the skin, whether gland or vessel, but beginning rather in the
areolar space they implicate secondarily one or other of the cutaneous viscera
or vessels, it may be the sudoriparous or the sebaceous glands, it may be the
hair follicles, it may be the perivascular spaces, or, lastly, it may chance to be
the lymphatics.

Although there are superficial differences between lupus vulgaris and lupus
erythematosus, the affections are closely allied; and they are in a general way
induced by a similar kind of causative influences. In the latter symmetry
and absence of a tendency to ulcerate are the rule, and constitute probably
the most important clinical differences.

Rare forms of the disease are occasionally met with. For instance, the dis-
ease in rare instances seems to partake of the nature of both eczema and
lupus — eczema-lupus. The very prolonged duration of the patches, their
obstinacy, their slow extension by infection at the borders, and, above all,
the fact that when cured they leave scars, sufficiently prove them to be
lupus ; now and then the patient has patches of eczema on other parts which
do not assume lupus characters. Another rare form is acne-lupus, the same
as described by Fox under the name lupus follicularis disseminatus. The
disease is a combination of acne and lupus, or, more correctly, perhaps, lupus
attacking acne spots. Psoriasis lupus, nsevus-lupus and other rare cases
illustrating combinations of one or more diseases with lupus are also referred
to. Recent observations as to the specific bacillus as the cause are mentioned,
but the author on this point expresses neither concurrence nor dissent.

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

VIIITINO OBSTETRICIAN TO TIIR PIIII.AIIEI.PHIA HOSPITAL.

Conception with Imperforate Hymi

Imperforate hymen, preguancy and dilated urethra are illustrated by a
case reported by Zinnstag (Omtralblatt fit r (iijnakologk, No. 14, 1888). The
patient had menstruated without difficulty, and conception followed repeated

OBSTETRICS. 205

coitus. At labor examination revealed an urethra dilated by coitus; the pos-
terior wall of the bladder distended by the head ; imperforate hymen. The
latter was incised and labor proceeded to a successful termination. The
lying-in period was normal.

The patient could give no history of bladder trouble, or menstrual derange-
ment ; an imperceptible opening must have existed in the hymen, through
which menstrual blood passed (as none was found on incising) and sperma-
tozoa entered.

Double Uterus and Vagina.

Tauffer reports, in the Centralblatt fur Gynakologie, No. 15, 1888, a case
of double uterus and vagina in a multipara; the condition had not been
recognized in previous labors, although the retention of decidua in one uterus
had caused fever and pain after the other uterus had expelled a child.

From his study of the case Tauffer concludes that both uteri had been
pregnant and had borne, and that simultaneous pregnancy, or superfceta-
tion, is possible in both. If only one uterus is pregnant the other might
delay labor as a small tumor would do. Decidua formed in the non-preg-
nant uterus during single pregnancy, and caused hemorrhage and endo-
metritis, whose location was not recognized.

Fatal Ptomaine Intoxication during Pregnancy.

GkJSTAVZ Braun ( Winter medicinische Preste, No. 19, 1888) reports the
case of a multipara, seven months pregnant, who died from pulmonary
oedema, after delivery. The urine contained casts and albumen.

Paultauf, on post-mortem examination, found fatty liver, fluid blood,
nephritis and cerebral oedema. Microscopically, multiple rupture of capilla-
ries with extravasation of blood was found in the liver.

Paultauf and Bamberger, from these conditions and the hyperaemic
condition of the intestines, diagnosed ptomaine intoxication ; the patient had
eaten partly decomposed flesh a few days previous.

Scarlatina during Pregnancy and Parturition.

Meyer {ZeiUchrift fur Geburtthulj'e, Band 14, Heft 2) analyzes twenty-one
cases. He found it impossible to detect the medium of contagion. The
period of incubation was from three to five days.

In six out of twenty -one cases the disease ran a mild course without com-
plications affecting the genitals. In eight pronounced inflammations of the
genitals occurred, with two deaths from sepsis.

The diagnosis is usually not difficult; cases complicated by sepsis furnish
difficulties in recognizing the disease. The prognosis Meyer thinks less
unfavorable than commonly supposed. Scarlatina may result in septic infec-
tion, usually through wounds of varying severity in the genitals, when the
prognosis becomes doubtful. Puerperal scarlatina resembles surgical scar-
latina in the formation of diphtheritic ulcers in lesions existing before
infection.

206 PROGRESS OF MEDICAL SCIENCE.

Treatment is antisepsis, as applied to parturients. Vaginal examinations
should be as infrequent as possible.

Of the children, two were stillborn ; four disappeared from observation.
Twenty children were nursed by women having scarlatina: one of these died
of erysipelas; one of scarlatina, post-mortem examination revealed catar-
rhal pneumonia and enteritis. The remaining children did not contract the
disease.

Points of especial interest in scarlatina occurring in parturients are : (1)
short incubation period (three to five days) ; (2) prompt appearance of erup-
tion which becomes diffuse, and is dark red in color; (3) angina is rarely
well marked.

The Albuminuria of Pregnancy.

Barnes {Lancet, May 12, 1888), in view of recent discussions "on transient
albuminuria," cites the kidney during pregnancy as the best example of the
condition of nervous and vascular tension which admits of albuminuria, but
is not nephritis. Analogous to this condition is the kidney in scarlatina.

Barnes regards neither condition as pathological.

The Electrical Treatment of Abortion with Retention of

Secundines.

Fry (American Journal of Obstetrics, June, 1888) reports a case in which,
one year after operation, fragments of membrane were expelled and general
hemorrhage checked by galvanism, the positive pole within the uterus, and a
maximum current of ninety milliamperes being employed for from six to ten
minutes.

He believes that tissue retained after abortion is of feeble vitality. The
positive pole of the galvanic current produces coagulation of tissue (as an a< i<l
does), obliterates bloodvessels, destroying the vitality of retained tissues, and
promotes exfoliation and expulsion.

A Case of Missed Labor.

Goth reports [Archivfur Gynakologie, Band 32, Heft 2) the case of a priori*
para in whom foetal life was destroyed by a fall at eight months pregnancy.
Labor did not come on, but necrosed foetal tissue and pus were discharged,
and the patient contracted septicaemia. Efforts to remove the foetal remnants
failed ; twenty months after labor should have occurred a vagino-rectal fistula
formed, with discharge of necrosed tissue. Two years after conception, under
deep oarooaia, the cervix was split, impacted foetal bones were removed, and
the uterus was emptied and disinfected; recovery followed.

From th literature consulted, G6th adduces multiple intra-mural fibro-
mata and disease of the endometrium as causes for missed labor.

Version before Labor for Foztal Malpositic

Ayf.RS (New York Medical Record, No. 21, 1888) reports three cases of
breech presentation, one face presentation and two cross positions, in which

OBSTETRICS. 207

he produced l normal oecipito-anterior position by combined external and
internal manipulation before labor.

In one case the membranes were ruptured unintentionally, but the success
of the manipulation was not interfered with. Lateral compresses were used
once to retain the foetus in proper position; in two cases the head was held
in place until labor began.

The Mechanism of Rotation in Head Presentations.

Olshausen [MSmckmer med. Wochensrhrift, No. 25, 1888) considers the
rotations which the head makes in head presentation to be caused by rota-
tions of the trunk.

The trunk is caused to rotate by the flattening of the uterus, antero-poste-
riorly, after the escape of the amniotic fluid, and the form of the uterus as
the birth progresses.

The Delivery of the After-coming Head.

Winckel, at the recent meeting of the German Society for Gynecology

mchener mediciiMche Wochenschri/t, No. 22, 1888), referred to twenty-one

methods of extracting the after-coming head. He considered that procedure

best which combined pressure externally with the maintenance of the head

in that position best suited for birth.

He accomplishes this as follows : The trunk and arms, when born, are
raised. Two fingers of the right or left hand toward which the face looks
are placed in the child's mouth at the base of the tongue and flexion is
secured. The trunk is then placed upon the forearm of this hand and with
the other hand pressure is made through the uterus upon the head.

As Wigand and Martin had previously described this method, he styled it
by their names. He had found delivery by this method readily effected with
a pelvic antero-posterior diameter of two and one-half inches. Martin had
employed it successfully in thirty-three cases, and he used it often in his
clinic.

Schultze, to avoid injuring the child's mouth, placed four fingers on the
forehead and made traction.

Martin believed that the method described by Winckel was superior to
the use of the forceps, or to operations for lessening the size of the head.

Breisky thought that pressure on the head should only be made when the
head is in the upper, and not in the thinned inferior uterine segment, to avoid
rupture of the uterus. The entrance of the fingers into the mouth was a
lesser evil, as it often introduced bacteria: he usually placed his fingers on
the chin, or upper jaw.

Winckel, in closing the discussion, limited the force exerted on the
child's mouth to the moderate traction necessary to secure flexion. He had
employed this method when the uterine segment was greatly stretched
without accident.

The Separation of the Placenta.

Fehlixg, at the recent meeting of the German Society for Gynecology
(Miinchener medicinitche Wocherucri/t , No. 22, 1888), reported that he had ex-

208 PROGRESS OF MEDICAL SCIENCE.

amined the mode of separation of the placenta in 100 cases, in which no
traction was made upon the cord.

In the great majority the placenta presented by its edge, as Duncan has
described. In five cases it formed a cup-like body, as Schultze has reported.
In these cases the membranes were separated on the maternal surface : in
one-third of the other cases the separation occurred on the foetal surface.
When the placenta presented by its edge the cord was long ; when a cup-
like presentation of the placenta occurred the cord was short.

Fehling believes that the last uterine contractions which expel the child
separate the placenta : the effusion of blood is accidental, and slight in normal
cases : such effusion is stopped by thrombosis. The uterine cavity becomes
oblong after the placenta is expelled.

He discouraged traction on the cord and interference with the natural
mechanism.

Schatz ascribed the placental presentation by its edge to uterine peris-
talsis.

Winckel had found two hours the average time required for spontaneous
expulsion of the placenta: the placenta was cup-shaped; the place of inser-
tion of the cord was anterior: the average blood loss was about seven ounces.
The child makes traction on the cord, causing the cup-shaped presentation.

Ahlfeld found the loss of blood, when the placenta was expelled sponta-
neously, twelve and one-half ounces, which ceased in five hours; there was
no after-bleeding.

Dohrn had found it necessary to deliver the placenta (Credo's method) in
only ten per cent, of his clinical cases : spontaneous expulsion was the rule.

Abdominal Hydatids Obstructing Labor.

Pinard {Annates de Gynecologie, April, 1888) reports the case of a priini-
para at term, with premature rupture of the membranes and labor delayed
for two days by a tumor filling the pelvis. The child lived, in head pre-
tation.

With Tarnier, Pinard prepared for Csesarean section, when the tumor was
displaced, punctured, and found to be a multiple hydatid of the abdominal
cavity. Natural labor followed, the child surviving. The mother died <>f
septicaemia four days afterward. In the fluid of the cysts was found a diplo-
coccus which may have been pathogenic.

Pregnancy and Parturition complicated by Carcinoma of thk

Cervix.

HEINRICIU8 (Nouvelles Archives d'Obstetrique, No. \. 1888) report! the ease
of a multipara suffering from carcinoma of the anterior lip of the cervix, who
bore a healthy child after a normal labor. The puerperiuin was normal ; the
cancer seemed to diminish slightly in size.

On her recovery from parturition the patient was operated upon, the tumor
removed, ami found to he eaneer. Death occurred a year after the operation.

Spontaneous birth occurs in the majority of cases o'f carcinoma uteri.

OBSTETRICS. 209

plicating pregnancy, when but one lip of the cervix is affected. In such cases
th<> interests of the foetus should be paramount, and pregnancy should not be
interrupted.

The Treatment of Fibro-myomata Complicating Pregnancy and

Labor.

1'hillips {British MtcSeal Journal, June 23, 1888) remarks that fibro-
myomata may induce labor, cause peritonitis, obstruct the passage of the
lotus through the pelvis and cause foetal malpositions. The placenta is often
adherent to the tumor ; uterine contraction and involution are interfered
with, and the disintegration of the tumor may cause sepsis.

Fibro-myomata in the body of the uterus disturb pregnancy. These
tumors, when in the lower uterine segment, may ascend; when in the cervix
fibro-myomata impede delivery.

Phillips has found 300 cases collected by Lefour ; he adds 59 cases in which
the tumor complicated pregnancy or labor, in which laparotomy was not
performed, and 47 cases in which it was.

Before the foetus was viable, abortion was produced in 4 cases, which
recovered. Myomotomy (abdominal section and removal of fibroids by liga-
ture) was performed 5 times, with 2 recoveries ; this operation is indicated
when the tumor is accessible, and causes great pain by distention. Miiller's
ablation (abdominal section, with removal of tumor and uterus) was per-
formed 19 times, with 12 recoveries. The stump was treated extra-perito-
neally in 13 cases, with 9 recoveries; intra-peritoneally in 6 cases, with 3
recoveries.

During foetal viability labor was induced 9 times, with 3 maternal and 7
foetal deaths. Playfair reports 3 cases in which the tumor was successfully
pushed up during labor; others have not been so successful. Munde* removed
successfully a large cervical fibro-rayoma per vaginam during labor.

Phillips has collected 33 cases of Caesarean section for this complication,
up to 1880, with a maternal mortality of 84.8 per cent. Since 1880 there
have been 13 Csesarean operations and 13 Porro operations with equal maternal
mortality, 69.22 per cent. ; the foetal mortality was slightly less by the Caesa-
rean operation. The mortality rate by Miiller's ablation was 36.8 per cent.

The statistics of Lefour's cases show that the forceps, embryotomy, version
and spontaneous birth resulted in maternal mortalities from 25 per cent, to 55
per cent. ; foetal mortality averaged 77 per cent.

Three Cases of Dystocia caused by Fibroid Tumors.

Porak (Bulletin de la SocUte Obstetricale^o. 4, 1888) reports a case of preg-
nancy complicated by a solid tumor of the left ovary, obstructing delivery,
which became dislocated during labor. The puerperal period was marked by
only slight disturbances of pulse and temperature, and the patient recovered,
with the tumor movable and situated at the brim of the pelvis.

A second case was one of multiple intra-mural and subserous fibroids, in
which abortion occurred at five months. The placenta, Porak thinks, was
adherent to the largest intra-mural fibroid ; it was retained, and was finally
discharged in fragments with necrosed tumor.

210 PROGRESS OF MEDICAL SCIENCE.

Septicaemia occurred, which was treated by intra-uterine injections given
through a double rubber catheter constructed for the patient ; the pelvis was
so occluded that neither the hand nor an inflexible sound could be introduced.

After two large pieces of necrosed tumor had been removed the patient
recovered, the uterine mucosa finally sloughing. At recovery the uterus was
slightly smaller than normally; the tumor had disappeared.

The third case was one of twin pregnancy with multiple fibroids, in which
abortion was performed at three months. A portion of one placenta was
retained. Injections of bichloride of mercury, 1 to 2000, followed by injec-
tions of saturated solution of boric acid were employed. Mercurial poisoning
supervened. The injections were changed to 1 to 4000, but without avail, the
patient dying of mercurial intoxication.

Cesarean Section for Fibroids complicating Pregnancy.

Bailey {Lancet, May 12, 1888) performed Caesarean section for fibroids in
the posterior cul-de-sac, which reduced the antero-posterior diameter to one
and a half inches. The operation was not especially difficult; several
fibroids were divided by the uterine incision. The cervix was patent, and
was tamponed with iodoform cotton.

The mother died of sepsis ; the child survived. Post-mortem examination
showed that the fibroids severed in the uterine walls had necrosed; the
uterine incision had not united, and retroflexion had occurred, which pre-
vented drainage of the uterus.

Extra-uterine Pregnancy; Laparotomy; Recovery.

Hawley (New York MedicalJournal, June 16, 1888) reports the case of a
pregnant multipara suffering from attacks of pain and hemorrhage. The
development of a cystic tumor as large as a lemon, in the cul-de-sac, pushing
the uterus forward and to the left, determined a diagnosis of extra-uterine
pregnancy.

Laparotomy was speedily done, and successfully. The cyst was removed
intact, composed of the outer extremity of the left tube, containing a foetus
of about six weeks growth.

He adds (in a foot-note) a case of unruptured tubal gestation at three
months which he had recently removed, and with probable recovery of the
patient. He urges enthusiastically laparotomy for early tubal pregnacy.

The Treatment of Extra-uterine Pregnancy.

Schwarz (Deutsche Gesellschaft fur Gynakologie, II. Congress. MQnoht nar
mediciniKc/ie Wovhcnschrift, No. 23, 1888) believed laparotomy and removal of
the sac the only rational treatment.

Extn-flterilM pregnancy is made frequent by gonorrheal and other pelvic
inflammations. Patients commonly perish from hemorrhage and shock ; he
had seen the loss of twelve ounces of blood cause death. When the tumor
is sub-diaphragmatic treatment should be expectant : when in the abdomen.
operative. One assistant, a nurse and antiseptic instruments are required. If

OBSTETRICS 211

the source of bleeding is not found, the ovarian or uterine artery should
be tied.

Win< ki:i. had treated seven cases by injections of one-half grain of
morphia into the sac: five recovered ; one had recovered under the treatment,
had the same condition again ; the foetus died, the patient died of gastric
hemorrhage. The second died of suppuration of the sac and sepsis, after
puncture through the vagina.

Veit had operated successfully on seven cases. He also operated on three
cases moribund after rupture of the sac ; one recovered.

Martin favored operation in uncomplicated cases. He had operated once,
unsuccessfully, after rupture.

Ah Extraordinary Demonstration of Schttltze's Method of
Resuscitation of the Newborn.

Wikrcinsky reports '{Centralblatt filr Gyitilkoloyie, No. 23, 1888) a case of
spinal apoplexy in a multipara, on whom, moribund, Csesarean section was
performed by Krassowsky (St. Petersburg).

The membranes had not been ruptured. The child showed no sign of life
when removed from the uterus. Schultze's method of resuscitation (swinging
the child by the chest and shoulders) was employed without success until
percussion showed air in the lungs.

Post-mortem examination revealed the following interesting points: Air is
introduced by his procedure into the lungs, and, possibly, into the stomach
and small intestine; as the membranes had not been ruptured no air could
have entered the child's lungs except by the procedure employed. The child
had not endeavored to breathe; showing that the foetus perishes from asphyxia
before the mother. The general post-mortem appearance was that of diffuse
oedema, with serous transudate, and not the usual hyperemia of asphyxia.

A Case of Wound of the Forehead of a Newborn Child,
occurring during Vaginal Examination.

Dohrn (Zeit*<-hrift fiir Geburts/iiil/e,Band 14, Heft 2) reports the case of a
child born of a normally shaped mother after a normal labor, which presented
a granulating surface of the superficial tissues over the left eye. Prompt
healing ensued, without evidence of constitutional disease.

By exclusion Dohrn concluded that a long finger-nail, on a physician who
examined the patient, caused the wound. The membranes had not, however,
been ruptured. Dohrn had seen another similar case.

The Danger of Metal in Nursing-bottles.

Reimann was led to investigate a nursing-bottle with metallic fastenings,
said to be " Britannia metal." Analysis showed twenty-five per cent, of lead
in the metallic parts, and reference to the records of the Berlin Bureau of
Hygiene revealed cases where liquids in contact with vessels containing less
proportion of lead had caused lead poisoning. Glass and rubber only should
be used. — Berliner klinisehe Wochenschrift, No. 19, 1888.

212 PROGRESS OF MEDICAL SCIENCE,

GYNECOLOGY.

UNDER THE CHARGE OF

HENRY C. COE, M.D., M.R.C.S.

OF NEW YOKK.

Sterility after the Birth of One Child (Ein-kind Sterilitat).

Kleinwachter [Zeitschrift fur Heilkunde, Bd. viii.) noted among 1081
women 90 who had remained sterile after bearing one child. On investigat-
ing the cause, he found that in nearly one-half of the cases it was due to in-
flammation of the uterus and its adnexa, or of the peri-uterine tissues, follow-
ing labor; in one-fifth it was attributable to displacements or neoplasms. On
the other hand, simple uterine displacements and catarrh, if uncomplicated,
should not always be regarded as the true cause of sterility, since in a con-
siderable proportion of the cases the husband is impotent. The latter factor
may be removed by the marriage of the woman with a second, more capable
man. For this reason the writer concludes that the prognosis in these cases
is never absolutely unfavorable.

Psychoses following Gynecological Operations.

Werth read a paper on this subject before the German Gynecological
Society at Halle {Miinchener med. Wochenschrift, June 5, 1888), in which he
stated that among three hundred operations on the female genital tract, he
had in six instances noted psychical disturbances (melancholia) due to the
operation. In two cases the trouble developed within a week after the opera-
tion, and in the others after a few weeks. The mental disturbances persisted
from two to over six weeks. Three were cured and three were not improved,
one of the latter committing suicide. In two cases the operation was total
extirpation of the uterus, in two, castration, and in two, irrigation of the
bladder (for the first time) for vesical catarrh. Three women had reached
the menopause; one was violently excited before the operation. The phenom-
ena could not be referred to iodoform poisoning, as the drug was used
sparingly or not at all.

Sanger, in discussing this paper, said that he recalled several cases in which
cerebral symptoms developed after gynecological operations. In two instances
these were clearly referable to iodoform, though little was used on the dress-
ings. In spite of the facts stated, he believed that patients with pelvic
troubles having a tendency to psychoses should be treated the same as other
women.

Martin agreed with Sanger that the operation was only an exciting eon
>>f the psychical disturbance. We should be cautious about operating upon
a patient with such a tendency, but in the case of women who are mentally
sound there is no danger of such trouble being caused by the operation.

Am ru.i> cited a case in wliieh marked psychoses were occasioned by the
use of a speculum.

GYNECOLOGY. 213

A New Method of Closing Cervico-vesico-vaginal Fistula.

raJblatt f'iir Gijnakologic, June 9, 1888) reports the case of a
multipara, in whom a large vesico-vaginal fistula was found in the upper
third of the vagina, eight weeks after the birth of her fourth child (by diffi-
cult version). It was closed at the first operation with eleven silkworm-gut
sutures, but urine still escaped into the vagina, so that it was supposed that
the operation was not entirely successful. On injecting milk into the bladder,
it was seen to escape from the os externum. The cervix was lacerated on
both sides, but it was necessary to dilate it with laminaria tents in order to
find the vesico-uterine fistula, which was situated about one-fifth of an inch
above the angle of the tear on the left side. In order to close it, the patient
was placed in the Sims's position, the cervix was split on both sides, and on
the right side the cervical was united to the vaginal mucous membrane, while
on the left the edges of the fistula were denuded and united by four silk
sutures; healing occurred by first intention and the patient had perfect
control over the bladder.

Referring to the fact that this variety of fistula is quite rare, the writer
attributes the difficulty hitherto experienced by operators and the frequency
of failure to their attempt to denude and introduce sutures, without first trying
to enlarge the field of operation. The advantages claimed for his method
were not only increased room and a clear view of the fistula, which could be
closed directly, but the assurance that, after healing, the cervix remained
patent. It was only applicable to lateral fistulae ; those situated in the me-
dian line must be treated according to the usual plan. Cauterization or
hystero-kleisis might be tried in case the attempt to close the fistula directly
was unsuccessful.

The Diagnosis and Treatment of Irregular Uterine
Hemorrhages.

Eichholz (reprint from Rratienarzt, 1887) holds that, in cases of metror-
rhagia in which the uterus is not considerably enlarged, it is seldom neces-
sary to palpate the uterine cavity in order to determine the exact pathological
condition. Endometritis fungosa may be suspected from the presence of sub-
involution, menorrhagia and leucorrhoea; retained placental fragments, from
the history of the case. However, it is unnecessary to make a positive diag-
nosis between the two conditions, since curetting is equally applicable to
both. Solid intra-uterine tumors may be recoguized by introducing the
sound, but, in order to establish the diagnosis, it is necessary thoroughly to
dilate and palpate the interior of the uterus. The latter procedure should
also be adopted when the presence of a malignant growth is suspected. Dila-
tation of the cervix should, if possible, be effected by means of blunt-pointed
dilators ; laminaria tents should be used only when the uterine tissue is very
rigid.

Malignant Adenoma of the Cervix Uteri.

Furst (Zeitschri/t fur Geburtshill/e u. Gynakologie, Band xiv. Heft 2) arrives
at the following conclusions from his studies on this subject :

1. Simple adenoma of the uterus, or glandular hyperplasia, which results

214 PROGRESS OF MEDICAL SCIENCE.

in increase in the number and size of the glands, without marked formation
of new cells, is to be regarded as benign ; nevertheless, it ought to be thor-
oughly excised, since it may become malignant.

2. Adenoma, or destructive glandular hyperplasia, which presents under the
microscope new-formed, atypical gland-processes surrounded by connective
tissue rich in round cells, and in which the glandular epithelium shows a
tendency to proliferate and invade the deeper parts, should be regarded as
undoubtedly suspicious. In such cases excision is not enough, but the entire
uterus should be extirpated, when a radical cure may be expected.

3. Adeno-carcinoma of the uterus, in which the normal glands are destroyed
and the deeper tissues are infiltrated with leucocytes and invaded by solid
epithelial processes, is unquestionably malignant, and even extirpation offers
only a doubtful chance of a radical cure.

4. The differential diagnosis between these various conditions depends less
on symptomatology than on the results of the microscopical examination.
Where malignant disease is suspected, a piece should be excised and examined
at once.

5. Operative interference, unless it is thorough, does more harm than good,
since it simply favors a recurrence of the disease, and recurrence in a worse
form.

Supra-vaginal Amputation.

Terrillon [Annates de Gynecology.' el iV Obstetrique, May, 1888) reports six-
teen cases of supra-vaginal amputation of the uterus for fibroid tumors, with
five deaths. His conclusions, based on the observation of sixty cases of
uterine fibroids, as well as on his studies of reported cases, are as follows :

Uterine fibroids may give rise to serious and even fatal results, by reason
of their size and the hemorrhages and mechanical pressure which they cause.
When serious symptoms arise, surgical interference is indicated — either castra-
tion or supra-vaginal amputation. The latter is a serious operation, the mean
death-rate at present being thirty per cent. Removal of the appeudages is
preferable, since it is less dangerous and is followed by diminution of the
hemorrhages and interruption of the growth of the tumor.

The Immediate and Remote Results of Operations for thk
Cure of Prolapsus Uteri.

Cohn [Zcitxrhrift fiir Grburfshiilf,- n . Gyn., Bd. xiv. Heft 2) reports the
results of his observations at Olshausen's clinic and in the private practice
of the late Professor Schroder— 105 cases in all. Of these, 74 were heard
from or were examined some time after operation ; 46, or 67.5 per cent., were
permanently cured.

His deductions are as follows :

1. The continuous catgut suture assures healing by first intention with
greater ease and rapidity of operation. It gives an even line of union and a
good, solid cicatrix.

2. Colpo-perineorrhaphy may permanently cure an extensive prolapse.
The reason why the percentage of cures in the case of hospital patients

alone was relatively so small (56.6 per cent.) was because the wounds were

GYNECOLOGY. 215

never really healed, the operation was imperfect, since only anterior colpor-
rhaphy was done, and, above all, the patients were not only obliged to work
hard, but pregnancy often occurred soon after they returned home.

In order to obtain permanent relief it is important to operate as early as
possible, to narrow the vagina as a whole (by doing a high posterior colpor-
rhaphy), and to build up a firm perineum ; the broader the latter, the firmer
the pelvic floor, and the more the vagina is carried forward, the stronger are
the chances of obtaining permanent cure.

MVOMATA AND MYOMECTOMY.

Communications on these subjects made before the German Gynecological
Society by Martix, Zweifel and Fritsch, possess considerable interest.

Martin, referring to 205 operations, which he had performed for the removal
of fibroid tumors of the corpus uteri, stated that in seventy specimens he found
evidences of retrograde processes, suppuration , fatty degeneration, etc. Eleven
showed general o?dema ; in the latter cases the most severe hemorrhages were
noted, and the patients were all very anemic. Sarcomatous degeneration was
observed in six, but in no instance were there appearances indicating a transi-
tion to carcinoma, although this form of malignant disease was associated
with myomata in nine cases, the cervix being affected twice, and the corpus
uteri seven times. The latter circumstance militated against the prevailing
notion that women with fibroid tumors were not liable to cancer of the uterus.

Zweifel, in discussing the treatment of the pedicle, criticised Olshausen's
method of dropping into the cavity the stump surrounded by a rubber liga-
ture, because necrosis was sure to follow. Schroder's method of suturing
the opposite edges of the stump, and then treating it by the intra-peritoneal
method, was open to the serious objection that it did not entirely control
the oozing. The speaker was accustomed to ligate the pedicle in several por-
tions, after tying off the broad ligaments in three sections. After cauterizing
the cervical canal, the rubber cord was removed and the stump was covered
with peritoneum. He had treated the stump in this manner in his last nine
operations, and had found that the hemorrhage was surely controlled, while
the stump could be trimmed down to the smallest possible size; his results
had been better than after his former operations.

Fritsch said that Zweifel was wrong in affirming that the stump necrosed
when the permanent rubber ligature was employed ; he had found it free from
danger. He had tried Schroder's method for a time, but had abandoned it,
because the mortality was seventy-five per cent. His method of performing
myomotomy was as follows: After lifting the tumor out of the cavity, he
ligates the broad ligaments, applies the temporary rubber ligature, then
divides the uterus in a vertical direction and excises the myoma. The uterine
wound is then closed, and the stumps of the broad ligaments are sutured
near the middle of the wound. The peritoneum is sewed to the edge of the
stump, so that the wound in the uterus is extraperitoneal. Lastly, the ab-
dominal wound is closed, the sutures being left long, and allowed to protrude.
They are removed gradually in the course of two or three weeks. He had
operated thus successfully nineteen times. In the case of large myomata,
growing outward between the folds of the broad ligaments, he preferred

216 PROGRESS OF MEDICAL SCIENCE.

enucleation ; the sac might then be drained through the vagina, or, better,
included in the lower angle of the wound. He believed that the enucleation
of myomata, when performed by this method, was a better operation than cas-
tration, being simple and safe, and furnishing positive results.

Olshausen, in discussing the above, stated that he had, in upward of 140
cases, dropped the rubber ligature into the peritoneal cavity, and he believed
that the danger of suppuration was slight if strict antisepsis was observed,
although he acknowledged that the stump was imperfectly nourished. He
thought that Zweifel's method required too much time, and that it might be
dangerous to transfix the cervix as described.

Dohrn had practised Olshausen's method 150 times and thought that no
danger was to be apprehended from necrosis of the stump, since the latter was
sufficiently nourished by the peritoneum.

Hofmeier, Fehlino, Breisky and Kaltenbach favored the extra-
peritoneal method, though the first thought that Schroder's plan, after it
had been improved, had a future before it. Martin said that he had
operated according to every method, and still preferred Schroder's.

Injury to the Bladder during Laparotomy.

Sanger (MUnohener mod. Wochensihrift, June 5, 1888), in a paper on this
subject, says that the bladder may be incised during laparotomy, by extend-
ing the abdominal wound too far downward; it may be torn while separating
adhesions, or it may be mistaken for a cyst and punctured. In a case of his
own the writer mistook a portion of the bladder, which was drawn upward
and embedded in adhesions, for the pedicle of a cyst. He ligated it in three
portions and divided it ; on recognizing his error, he drew the bladder up and
brought the peritoneum together around the stump, attaching the latter in
the abdominal wound. The patient had a moderate vesical catarrh, but re-
covered without having a fistula.

In another instance, in which the same accident occurred and was similarly
treated, a mural abscess developed four weeks after the operation and rup-
tured, leaving a fistulous opening into the. bladder which rendered a second
operation necessary.

In every case of laparotomy the operator ought to observe carefully if the
bladder is drawn upward, and the urachus is still partially patent.

Mknstruation after Double Oophorectomy.

An interesting discussion on this question took place at a recent meeting of
the Leipzig Obstetrical Society (C&itrathlnft J'iir Gijniikologie, June 2, 1888).
It was introduced by Hennig, who announced at the outset that he agreed
entirely with BischofF's theory of menstruation. So long as it was certain
that no remains of either ovary or a supernumerary gland was left at the
time of operation, a periodical discharge of blood from such patients must be
regarded as abnormal. He was inclined to believe that a small portion of
the cortex of one ovary, containing Graafian vesicles, might be included in
the ligature.

In the subsequent discussion, Sanger stated that out of forty cases of
castration he bad obttrvtd continuous periodical hemorrhages in only two,

GYNECOLOGY. 217

in one of which the persistent flow was due to retro-displacement of the
uterus; it ceased after hysterorrhaphy had been performed. The speaker
concluded that when no other " focus of irritation " is present, persistent
menstruation after castration can only be due to some disease of the uterus.
Zwkifel cited a case of recurring hemorrhage after double salpingo-
oophorectomy, which eventually ceased spontaneously. He believed that
the metrostaxis would always cease in time, and that such would be found to
be the after-history of most of the reported cases of persistent menstruation.

Intestinal Obstruction after Ovariotomy.

Hirsch [Archiv fitr Gyndkologie, Bd. xxxii. Heft. 2) presents at length
the results of his observations and studies on this important subject. In-
testinal obstruction following laparotomy is due, he says, to three causes.
It may be direct, where a coil of intestine becomes adherent to the ab-
dominal wound, and occlusion results from the traction of the cicatrix.
Secondly, simple aseptic peritonitis may follow the operation, resulting in
the formation of adhesions which imprison the intestines, limit the peris-
taltic movements, and thus lead to fecal impaction and complete obstruc-
tion. Thirdly, without the occurrence of any inflammation whatsoever, a
loop of intestine may be imprisoned between the pedicle and the pelvic
or abdominal wall, especially after supravaginal amputation when the
stump is treated according to the extra-peritoneal method. Intestinal occlu-
sion is comparatively common, Sir Spencer Wells having reported 11 deaths
from this cause in 1000 cases of ovariotomy. Usually the obstruction occurs
soon after the operation, but several years may elapse before the accident
takes place. In one instance, death from this cause occurred nine years
after. The symptoms are those usually accompanying obstruction — persistent
vomiting, constipation and tympanites. Death is preceded by symptoms of
collap>e ; the pulse and temperature may remain normal, or there may be
high fever, while no evidence of acute peritonitis is found at the autopsy.

The diagnosis is always rather obscure, so that the surgeon shrinks from
reopening the cavity. Obstinate constipation and fecal vomiting are the
only positive signs, since vomiting, tympanites and failure to pass gas per
rectum may be due to diffuse peritonitis, although in a mild degree they are
a common accompaniment of abdominal operations before the bowels have
moved. Obstruction is recognized most clearly when it occurs some days
after operation. The seat of the occlusion can sometimes be recognized by
palpation, especially if it is in the neighborhood of the incision. There are
more pain and vomiting when the small intestine is imprisoned, but less
meteorism than is present when the large gut is occluded. Diminution of
the daily quantity of urine and an increase in the amount of indican point to
obstruction of the small intestine.

The prognosis is extremely unfavorable. Of the fourteen cases collected
by the writer, only one recovered — after secondary laparotomy.

With regard to prophylaxis he quotes from various authorities, notably
Kaltenbach, Miiller and Olshausen. The former advises spreading out the
omentum carefully over the intestines, after separating all adhesions, avoid-
ing injurj' of the parietal peritoneum (by bruising, the cautery, etc.), and

218 PROGRESS OF MEDICAL SCIENCE.

closing the peritoneal wound accurately. Miiller discards abdominal band-
ages after the operation, except in cases in which it is desirable to check
oozing, and washes out the cavity with large quantities of sterilized water if
there have been intestinal adhesions. Since Kaltenbach has irrigated with
bichloride solution he has not seen a case of intestinal obstruction, while out
of twenty-four in which carbolic acid was used, there were three fatal cases.

The obstruction has been removed by washing out the stomach. An opera-
tion should be done early, if at all ; when performed a short time after the
primary laparotomy it offers the best results.

Carcinoma of the Fallopian Tube.

Orthmann read a communication on this subject before the Gynecological
Society of Berlin {Centralblatt fiir Oynakologie, May 26, 1888). Alluding to
the fact that Kiwisch had found carcinoma of the tube only eighteen times
in seventy-three cases of cancer of the uterus, and Dittrich only four cases
out of ninety-four of general carcinomatous disease, the reader stated that
his researches in the literature of the subject had yielded accurate descrip-
tions of only thirteen cases, in nine of which the uterus, and in four the
ovaries were primarily affected. The medullary form of cancer is most
common ; it may originate in either the mucous, muscular or serous coat
of the tube. Papillomata of the tube (recently described by Doran) may
readily be mistaken for malignant growths. Three cases of carcinoma tubae
occurring in Martin's clinic were described, in one of which the disease was
primary. Orthmann concluded from this that primary cancer of the tube
does occur, although in the great majority of cases it is secondary to disease
of the uterus.

In the discussion which followed, Huge said that he had never seen a case
of primary carcinoma tubse ; he was inclined to believe that disease of this
duct is more often secondary to malignant affection of the ovaries than to
cancer of the uterus.

Winter recalled an interesting case of carcinoma of the ovary, in which
the disease appeared to have spread by contiguity to the adherent abdominal
end of the tube, the rest of the latter being perfectly healthy.

Olshausen cited a case of double ovarian tumor, in which, after removal
of the cysts, a mass as large as a hazelnut was found in the left tube;
microscopically it showed the structure of endothelioma. Olshausen thought
that the distribution of the lymphatics explained the fact that the tubes
share so rarely in malignant disease of the ovaries.

Note to Contributors. — All communications intended for insertion in the Original
Department of this Journal are only received with the distinct understanding that they
are Bent to this Journal alone. Gentlemen favoring us with their communications are
considered to be bound in honor to a strict observance of this understanding.

Liberal compensation is made for articles used. Extra copies, in pamphlet form, will,
if desired, be furnished to authors in lieu of compensation, crowded the request for them
be written on the manuscript.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES,

SEPTEMBER, 1888.

CONTRIBUTION TO THE DIAGNOSIS AND SURGICAL TREAT-
MENT OF TUMORS OF THE CEREBRUM.

By R. F. Weir, M.D,

SURGEON TO THK NEW YORK HOSPITAL ; PROFESSOR Of CLINICAL SURGERY IX TUB COLLEGE OF PHYSICIANS
AND SURGEONS, HEW TORE ;

AXI»

E. C. Seguix, M.D.,

MEMBER Or THE ASSOCIATION Or AMERICAN PHYSICIANS, ETC.
III.

Remarks on the Surgical Removal of Brain Tumors.
[By Dr. Weir.]

The attention of surgeons was instantly arrested, in 1884, by the
publication in the Laaeet of December 20th, of that year, of an account
<>f the excision of a tumor from the brain, published by Dr. Hughes
Bennett and Mr. Godlee. The patient presented signs of incomplete
and progressive left-sided hemiplegia beginning in the face and tongue,
and of double optic neuritis, which, with other symptoms of less impor-
tance, led Dr. Hughes Bennett to arrive at the following conclusions:

First, that there was a tumor in the brain; secondly, that this growth
involved the cortical substance; thirdly, that it was probably of limited
size, as it had destroyed the centres presiding over the hand, and only
caused irritation without paralysis of the centres of the leg, face and
eyelids which surrounded it ; and, fourthly, that it was situated in the
neighborhood of the upper third of the fissure of Rolando.

This diagnosis having been made on the 25th of November, 1884, Mr.
Godlee trephined the skull over the region corresponding with the upper
part of the fissure of Rolando. No tumor was visible after the dura mater
iru slit up, but the ascending frontal convolution seemed to be somewhat
distended. An incision about an inch long was made into the gray matter

YOL. 96, NO. 3.— SEPTEMBER, 1888.

220 WEIR, SEGUIN, CEREBRAL SURGERY.

in the direction of the bloodvessels, and at a quarter of an inch below the
surface a morbid growth was found. This was carefully removed and it
proved to be a hard glioma about the size of a walnut. It was easily enucle-
ated. The hemorrhage was arrested by means of the galvano-cautery and
the wound brought together by sutures. The patient did fairly well up
to the twenty-sixth day, when he was suddenly seized with a rigor, fever
and pain in the head. A hernia cerebri of large dimensions supervened and
death occurred on the twenty-eighth day after the operation. At the autopsy
the brain substance was normal, though suppurative meningitis was found at
the lower border .of the wound spreading downward toward the base of the
brain on the same side.

This brilliant, though unsuccessful, operative interference for the
removal of a cranial growth was followed, after a lapse of some time, by
another fatal case in February, 1886, and was reported in the Pacific
Medical and Surgical Journal for April of that year by Drs. J. O.
Hirschfelder and Morse, of San Francisco.

In this instance the cerebral disease had existed for eighteen months, begin-
ning with occipital pain and paresis of the left leg and progressing with double
optic neuritis up to involvement of both upper extremities and the left side
of the face. The diagnosis was made of a tumor of the brain situated in the
motor centres around the sulcus of Rolando on the right side, and from the fact
that the face, arm and leg centres were apparently affected, the middle portion
was supposed to be with certainty involved; or, more correctly stated, it was
believed that the neoplasm was located in the middle portion of the gyrus
post-centralis.

Three buttons of bone were removed by a trephine, and an opening made
through the skull three inches across. The portions of cranium removed were
unusually thin. On cutting through the dura mater, the parts beneath imme-
diately pushed through the opening, protruding half an inch beyond the bone
level, and presented an abnormal appearance. No pulsation of the brain was
observed. The outgrowth was excised only in part, it being difficult to
separate it entirely from the healthy brain tissue. The mass removed was
about two ami a half cubic centimetres in size and a microscopic examination
proved it to be a glioma. The wound was dressed with lint soaked in oar-
bolized oil and over this a thick layer of cotton batting. On the seventh day
death resulted from encephalitis. No post-mortem was allowed.

Dr. Hirschfelder, in concluding his report, says that the unfavorable result
after the operation in this case must be ascribed to the character of the tumor.
The soft glioma was continuous with the adjoining brain tissue, so that its
complete separation was impossible without destruction of a large portion of
the cerebrum. Had it been a hard tumor that could have been readily iso-
lated, it is very probable that the patient would have recovered.

The most marked impetus to the treatment of cerebral tumors was,
however, imparted by the publication of a paper entitled "Brain Sur-
gery," by Victor Horsley, in the British Medical .Journal of October 9,
1886. Mr. Horsley, I may here say, combines in himself the skill of a
surgeon with the knowledge of a neurologist. In this article there are
reported, in addition to two cases of brain excision for epilepsy, the
details of a case of cerebral tumor successfully removed by an operation.
I transcribe the latter only briefly :

The tumor was tubercular in character, and was found in the ascending
frontal and parietal convolutions at a line of junction of their lower and
middle thirds. Before closing the wound in this instance, the centre of the

WEIR, SEGUIN, CEREBRAL SURGERY. 221

thumb area, which had caused the most signal symptoms, was removed by a
free incision. No tubercular disease was recognized elsewhere in the body.

In this paper Mr. Horsley set forth the operative technique which his
experience on animals, as well as on human subjects, had led him to
adopt ; in this were several departures from the ordinary methods of
operation in cranial injuries, etc. In addition to a strict antisepsis, he
makes an oval scalp wound instead of the ordinary crucial one, and re-
sorts to a very large opening in the skull, using a trephine two inches in
diameter, and replacing the chopped-up fragments of bone when possible.
The dura mater he directs to be incised in a circular manner for four-
fifths of the circumference, and the flap to be turned back and replaced
and held in tfitu by sutures at the close of the operation. In incising
the brain, the cut, he says, should be vertical and directed into the
corona radiata to avoid damage. Hemorrhage should be checked by
ligature or by pressure. The cautery should not be used. Drainage of
the wound is necessary. Stress was laid by him, moreover, on the im-
mediate bulging out of the brain as indicative of a tumor. This is not
met with, he states, in healthy animals on whom he has tested this ex-
perimentally. This is, therefore, a symptom of intracranial pressure of
high value.

Subsequently, in The American Journal of the Medical Sciences
for April, 18<s7. Mr. Horsley gave, with, however, only very scanty
outlines, a case in which, at the time of the operation, there were absolute
hemiplegia and coma, produced by a tumor which, when removed,
gbed four ounces; and he also reported a third case of a diffuse tumor
which invaded the shoulder region and caused constant clonic spasm of
the shoulder- and elbow-joint, besides severe fits beginning in the same
region. Subsequently the same surgeon, in the British Medical Journal of
April 23, 1887, gave further details of these two cases, in which the im-
portant item was presented that the patient from whom the large tumor
was removed lived for three months, when symptoms of recurrence began
to show themselves, and death finally took place six months after the
operation, and that in the other case, up to the date of the report, a year
and more after the operation, no recurrence had manifested itself.
Horsley also reported in the last article the removal of a fourth tumor,
which, however, involved the right lobe of the cerebellum, and in which
death occurred nineteen hours after the operation. In this case the tumor
was tubercular in its character, and with it existed tuberculosis of other
ra. In the other two cases the tumors were sarcomatous in nature.

In February of last year Dr. W. R. Birdsall,1 of New York, placed
under my surgical care a case of tumor of the brain which had been

1 Brain Surgery. ReraoTal of a large Sarcoma, causing Hemianopsia, from the Occipital Lobe. By
W. R. Birdaall and B. F. Weir. Medical News, April 16, 1887,

222 WEIR, SEGUIN, CEREBRAL SURGERY.

localized by him in the right occipital region, hemianopsia being the
principal symptom. An opening two and three-fourths by two and a
quarter inches was made in the occipital region of the cranium, and a
tumor weighing five and a quarter ounces removed. The patient, how-
ever, succumbed from the shock and hemorrhage which followed the
operation. In this case, also, pulsation was absent when the skull was
cut through.

Chronologically, the case which is the subject of the present paper
would come next in order, but as a wide and proper construction of the
term cerebral tumor should embrace those of the cerebellum, to the
foregoing list should be added two others, the account of one of which
appears in the Lancet of April 16, 1887, and was presented by Mr.
Bennett May, of Birmingham, England.

From the symptoms, a tumor in the cerebellum was believed to be indicated,
and the paralysis which existed in the right external rectus led to the con-
clusion that the tumor was in the right lobe and was growing downward and
forward and compressing the right sixth nerve. It was thought also that the
tumor was probably tubercular, though no other part of the body gave evidence
of this disease. As the mode of incision for attaining access to a growth in
this region has not heretofore been given, it is shortly detailed. A curved in-
cision, with the convexity upward, reaching a little above the external occipital
protuberance, was carried by Mr. May across the back of the head from one
mastoid process to the other. The scalp and subjacent parts were then carried
down as a flap by separating all the muscular attachments from the bone
until the neighborhood of the foramen magnum was reached. A trephine
was applied and this opening enlarged easily by a rongeur forceps, as the
bone was thin. The extreme bulging of the dura mater gave evidence of great
intracranial pressure. The membrane was opened and turned up by incisions
along the three sides of the aperture in the bone. The cortex of the cerebrum
appeared quite healthy, but at one spot a little outside the centre of the ex-
posed space palpation gave an ill-defined feeling of hardness beneath the
surface. An incision was here made with a tenotome, and, on entering the
finger, there was detected the hard mass of a tumor nearly an inch below the
surface. It was dug out of its bed cleanly by the handle of a small teaspoon.
It was larger than a pigeon's egg, hard and horny on the exterior and ease-
ating in the centre. The hemorrhage was trifling, but the patient, however,
succumbed from shock a few hours afterward. No post-mortem examination
was permitted.

On the 1st of October Mr. Suckling, of Birmingham, also removed a

tumor from the cerebellum by a nearly similar procedure, reversing,

however, the incision through the scalp. The account of this case was

published in full in the Lancet of October 1, 1887.

After a crucial incision had been made through the dura mater the cere-
bellam at once bulged into the wound, and its tissue appeared darker in eolor
thin normal. No hardness could be felt with the finger. The brain tissue
was therefore incised. The hemorrhage which followed was very tree. A finger
Introduced into this wound reeogoiaed "softness" in all directions. Pert of

the cerebellar substance was cut away and the wound closed after a drainage
tube had been placed in it. The patient died within forty-eight hours after
the operation. The left lobe of the cerebellum was found enlarged and hol-
lowed out in the centre. This cavity was seen to be surrounded by soft
ular tissue of a pinkish color which, under the microscope, showed the
structure of a glioma. The new growth had evidently occupied the whole of
the left lobe and had also invaded the middle lobe.

WEIR, SEQUIN, CEREBRAL SURGERY. 223

In the Medical X>'ws of December 24, 1887, is an interesting case of
cerebral tumor only, however, scantily referred to, removed by operation
by Dr. W. W. Keen, of Philadelphia, which weighed three ounces and
ti>rty-niue grains, and which extended from the fissure of Sylvius into
the first frontal convolution, and from near the fissure of Rolando into
the bases of the three frontal convolutions.

The initial symptom in the case was an epileptic attack with right-sided
deviation of the head and eyes, followed by paralysis of the right arm and
leg, and by aphasia The tumor was a fibroma. Ten days after the extirpa-
the patient had a sharp rise of temperature to over 104°, with diarrhoea
and marked bulging of the flap; paresis of the right leg; paralysis of the
right arm and right lower face with aphasia. These severe pressure symp-
toms, however, subsided and recovery took place.

From the foregoing presentation of surgical work in the cranial
cavity for the removal of neoplasms, it would appear that the credit of
the inauguration of this important improvement was due to the activity
of the English mind, but on October 1, 1887, in the Lancet appeared a
modest " Contribution to Endo-cranial Surgery," by F. Durante, of
Rome, which showed that in May, 1884, prior even to Godlee's opera-
tion, Durante had removed a tumor the size of an apple from the brain.

From thaloss of memory and of the sense of smell, in the absence of other
nerve symptoms save melancholy and a sense of vacuity in going about,
Durante was led to believe in the presence of a tumor beneath the cranium.
The displacement of the globe of the eye, which also existed, led him to ex-
pect that the tumor had penetrated the superior arch of the orbital cavity.
A large opening in the left frontal bone was made and the dura mater found
to have been perforated from absorption by the tumor opposite to the frontal
eminence. The tumor was scoopea out piecemeal at first, and subsequently
the mass was enucleated. The hemorrhage was slight and easily controlled
by a hemostatic tampon of sublimate gauze. The tumor occupied the left
anterior fossa of the cranium. It extended to the right and rested upon the
cribriform lamina, which it had destroyed. Posteriorly, it reached to the clinoid
tubercles in front of the sella turcica. The left anterior cerebral lobe was
greatly atrophied. The orbital arch was decidedly depressed, but was not per-
forated, as had been anticipated. The patient made a perfect recovery. She
was seen four years later and was then in perfect health. The tumor under the
microscope presented a multiform fibro-cellular structure of sarcoma.

This case is not only of great importance chronologically, but is of
greater importance in respect to the possibility of permanent recovery
after removal of a sarcomatous tumor. In cases like that of Keen, a
fibroma, no recurrence is to be expected ; with sarcoma, even well encap-
sulated, the possibility of its return, as in other parts of the body, must
be considered, and especially as we are loath, in the brain, to go wide
from the tumor, a condition which, when complied with in other regions,
largely contributes to a permanent success when removing such neo-
plasms.

AVith infiltrating sarcoma and gliomata the prognosis must be very
discouraging unless increasing experience enables the surgeon to pro-
ceed with more boldness, since it must be permitted to assume the risk

224 WEIR, SEGUIN, CEREBRAL SURGERY.

of even increased permanent disability or of destruction of life itself in
such otherwise utterly hopeless cases.

Bearing on the point of the benefit to be derived from the operation,
attention should be given to the fact that in two of Horsley's cases in
which the tumors were sarcomatous, in one, the patient's lite was pro-
longed for six months, and in the other, the patient was still alive a year
and four months later.

It is also to be noted that in the three cases in which the tumor was
tubercular, in but one was evidence of the existence of this disease to be
found in other parts of the body, a fact somewhat at variance with the
statements of White on this subject.

It seems too early in the history of this operation for a decision to be
reached as to what kind of tumors may contraindicate an attempt for
their removal. It still appears proper surgery to undertake the opera-
tion of opening the skull (certainly as an exploratory procedure) for
those cases which indicate sufficiently clearly by symptoms that a pro-
gressing pressure, as from a tumor, an abscess, an intra- or extra-cerebral
blood-clot, or that a continued irritation effect, such as results from
cicatrices, gummous residua, or the like, is present, and not to be relieved
by the ordinary means of treatment.

Before proceeding to the consideration of the operative measures to
be observed I venture to allude to two more cases of cerebral tumor,
though in one, operated on by Dr. Markoe,1 some doubt is admitted by
that surgeon as to the nature of the mass removed. Its microscopic
revelations make it more probably to be an inflammatory changed
cerebral convolution.

The operation was performed on a young man, who hud, following a blow
on the left side of the head, great sensitiveness and headache over the site of
the injury, with frequent nocturnal epileptiform attacks. No paralyaifl
isted. Exploratory trephining was resorted to on the flattened portion of the
skull corresponding to the old injury. Nothing was found in the bone or
dura mater of an abnormal character. On cutting through the latter two
unequal masses of a rounded shape lying close to each other, about one inch
in diameter, were exposed and removed with the handle of the scalpel.
Subsequent examination showed this to be normal cerebral tissue, with a
deposit of small spheroidal cells in the lymph spaces surrounding the swollen
normal ganglion cells. The patient recovered from the operation after being
temporarily aphasic, and remained tree from pain and epileptic seizure up to
the date of the report, nine mouths afterward.

It is not without interest, perhaps, to epitomize a ease related by Dr.
Sands, in the Mnlical AVi/w of April 26, 1883, which not only ahowi
how success might have been achieved at an early date in the removal
of a cerebral growth, but I beg to present it, furthermore, as an example
of the advantages of always raising or incising the dura mater in these
exploratory operations. Had it then been resorted to, the credit of first

k1 of . Tumor | fr..m the ltrain. t>\ T. M. Markov, M.U., Medical News, November 5, 1887.

WEIR, SEGUIN, CEREBRAL SURGERY. 225

removing a cerebral tumor might have been attributed to American
surgery. It is true, that this case had for the localization of the trouble
the assistance of a well-defined traumatism, and, therefore, could not be
considered, even had it proved successful, as brilliant in the diagnosis
as are the cases that have been operated upon by Horsley and others.

Sands's patient had, two weeks after an injury, an epileptic seizure, which
was repeated at a week's interval, with right facial paralysis, and slight hemi-
plegia of the same side and aphasia. Tenderness was still felt over the site of
the original injury. Syphilis was denied. An exploratory operation exposed
the dura in front of the left fissure of Rolando, two inches above the ear.
Pulsation was absent. No fluctuation could be felt. A large hypodermatic
needle was thrust through the dura in three different places to the depth of
an inch, but nothing was withdrawn. In making two other punctures through
the dura, the needle met with considerable resistance, and the idea of a tumor
was suggested, but no further operative procedures were carried out. The
wound was closed with fine catgut sutures, and antiseptic dressings were
applied. On the eighth day after the operation death occurred from encepha-
litis. At the autopsy, the dura around the bone opening was found adherent to
the pia, and just underneath it, and behind the posterior central convolution,
there was found a gummy tumor one inch in diameter.

Although the clinical experience so far obtained in this branch of
cerebral surgery is not large, yet it suffices, even in its limited extent, to
settle some two or three points of interest. The first of these is of weight
when we admit that, though localization of brain lesions has become
tolerably exact in certain portions of the brain, yet even in these por-
tions— motor regions — doubts may arise which can only be settled by use
of the exploratory operation. Our slight experience has, however,
shown in the case of large openings in the cranium, that when the
operation is conducted under antiseptic precautions, it is devoid of any
great risk in itself, and that the taking away of the support to the cere-
bral mass is not followed, as one might naturally be led to expect, by
serious oedema of the brain.

As to how this exploratory operation should be conducted, this will be
deferred for subsequent consideration.

Although large openings in the skull are so well borne, a point that is
admitted by Bergmann in his recent article,1 yet this same surgeon con-
tends, from theoretical reasons apparently, against surgical procedures
being applied for the removal of large tumors, on account of their
proneness to be followed by fatal oedema, and he sets forth a dictum that
large tumors, or patients the subjects of any tumor, in a state of coma
due to existing oedema, should not be operated upon. To disprove this,
it will be recalled that in one of Horsley's cases a tumor was removed
which weighed four and a half ounces, and which, at the time of the
operation, was associated with absolute coma and hemiplegia, and yet

1 Die Ctairurgische Behandlung von Hirnkrankheiten. Archir filr Klinische Chirurgie, Band 36,
1888, Heft. iv.

226 WEIR, SEGUIN, CEREBRAL SURGERY.

recovery took place ; and Keen's case, in which the tumor weighed over
three ounces, may also be cited.

Another point that comes to notice from a consideration of the cases
quoted in thi.s paper, is that the operative technique is not a difficult one,
and that the hemorrhage which occurs from the scalp wound, and from
the dura or pia mater, .though at times troublesome, is easily controlled.
I beg also to state here a little more particularly, because some confusion
has occurred from the history of the case that I reported of the removal
of a large cerebral tumor in the occipital lobe (my first and fatal case,
and previously alluded to in this paper), that the wound was not closed
until after all the oozing of blood had been apparently checked by the
temporary pressure of sponges passed into the cranial cavity, and retained
there for a short time. The slight weeping of blood that was seen here
and there over the depressed brain surface, after the final taking away
of the sponges, was easily controlled by the light pressure of the iodo-
form gauze tampon resorted to. The hemorrhage that imperilled, or
contributed probably to the patient's death, developed itself later. Had
it been noticed at the time, the expedient which a review of the case
suggested, of using a clamp for a vessel deep in the cranial tissues, would
have been employed. Hemorrhage of itself cannot be considered, in
my opinion, as an objection, or a contraindication to the operation, since
this can be checked as well in this region as anywhere else. The prin-
cipal difficulty that stares us in the face, from a surgical standpoint, is
that these tumors, being often situated some little distance beneath the
surface, the fact of their being encapsulated or infiltrated, cannot be
determined until the operative stage has been considerably advanced.
An encapsulated tumor is justifiable to be removed, no matter what its
size may be. If one meets a tumor infiltrated into the surrounding
brain tissues, it goes almost without saying, that we can hardly expert,
unless it is comparatively small, to remove it satisfactorily without per-
haps doing irretrievable damage to the surrounding parts, or, possibly,
without seriously imperilling the patient's existence, yet 1 fancy that the
present case, reported by Dr. Seguin and myself, may be thought worthy
of imitation in deposits of this kind and of moderate size. In this case,
it must be admitted that the growth cannot be said to have been at all
widely removed, and it has been an agreeable surprise to find, so long
after the operation, no decided evidence of a recurrence of the tumor.

The statistic! which all who are interested in the study of cerebral
tumors naturally refer to, by reason of their thoroughness, are those of
Dr. \Y. I lab- White, in (iuy's Hospital ReporU.1 I beg, for the sake of
completeness, to submit a synopsis of this report, although it has been
partially used by me elsewhere.

i Thlr.1 Series vol. 28, 188B-86.

WEIR, SEGUIN, CEREBRAL SURGERY. 227

Out of White's one hundred cases of autopsies of cerebral tumors,
forty-five were tubercular, and more than half of these occurred in chil-
dren under ten years of age; and when found in adults, there was usu-
ally tubercular disease elsewhere. Like the carcinomatous tumors, five
in number, all were multiple and secondary. Both these kinds of tumors
are, therefore, unsuitable for surgical consideration.

This statement is corroborated by Bergmann chiefly for the reason that
it is not possible to enucleate tubercular masses in the brain with a sharp
spoon, as in the bones or skin, and also that the operation itself might favor
the dissemination of the tubercular process over the brain membranes,
and give rise, in this way, to tubercular meningitis. The only experience
SO far that we have had in this class of tumors, in respect to their surgi-
cal behavior, is the cerebellar tumor of Bennett, which not only existed
primarily but was also easily and completely removed, though a fatal
result followed the operation. Horsley also removed, with a similar
bad result, a cerebellar tumor of tubercular character, weighing seven
drachms, without operative difficulty, but the autopsy showed the other
statement to be correct, since generalized chronic tubercles were found
in various viscera of the body. Out of twenty-four gliomata and ten
sarcomata (the cysts being only four in number and too rare to be
considered), wbicb tumors alone offer a reason for surgical interference,
there were only four growths which could have been removed with any
certainty, two of which were gliomata and situated in the cerebellum.
Only one of the ten sarcomata was removable. White, moreover, found,
when considering the question clinically as to how many of these hun-
dred tumors could have been sufficiently localized as to warrant a surgi-
cal interference, that three tubercular tumors and four gliomata, one
sarcoma, two cysts, one myxoma and two of the three doubtful growths
might have been removed, or, in other words, that about ten per cent, of
the number might have been operated upon, provided a correct diagnosis
could have been made.

The difficulties that attend this branch of surgery must be constantly
kept in view, not so much in the operative technique as in the possibility
of not finding the sought for tumor. I have already reported1 one case,
in wh^ch failure resulted, though the patient lived several months after the
operation. Another case has been reported by Dr. Graeme Hammond f
a third was operated upon by Dr.Gerster, of New York ; and a fourth by
Dr. Markoe. The two latter have not yet been published. One in-
structive point has appeared in connection with the case of my own,
the first one in this short li?t of unsuccessful cases, which was, that
though no tumor was found, not only was recovery prompt from the
operation, but the patient's symptoms were materially improved, from

1 Medical News, March 5, 1887. » Medical Newg, April 23, 1887.

228 WEIR, SEGUIN, CEREBRAL SURGERY.

the relief of the pressure by the taking away of a goodly portion of
the skull, for in this case I did not replace the bone, as I did in two
other instances. This result may afford an additional reason for the
justification of an exploratory operation, since, if no tumor be found,
relief to the brain pressure can be at least temporarily obtained.

This relief of cerebral pressure can, I think, moreover, be properly
applied in other severer conditions, such as, for instance, progressing
apoplectic hemorrhage, etc.1

Remarks on the Operative Procedures. — While no surgeon can yet be
said to have had an experience in modern brain surgery sufficient to
speak dogmatically as to methods of technique, yet the outcome from a
study of the cases of others, together with the personal care of seven of
these important cases — three of tumor, three of cerebral abscess and one
of epilepsy — has caused me to appreciate the value of certain points
which I now venture to bring forward, some in reiteration, and not of
my own evolution, and some of novelty.

The use of a curved flap, both of the scalp and of the dura mater,
which was suggested by Horsley, is of decided advantage in securing
protection to the brain after the completion of the operation. But the
large incision in the skin brings with it an increased annoyance from
the hemorrhage which often, persists from the slipping of ligatures and
clamps from the dense tissues of the scalp. I had intended, in my next
case, to transfix the scalp parallel and just exterior to its edge with
acupressure needles, to secure a clean operative field, but I find that the
suggestion made to me by Dr. M. A. Starr, of tying a rubber band tight 1 y
around the head on a line with the occipital protuberance, is of con-
siderable value. The arterial hemorrhage is thus completely controlled,
and the remaining venous flow from the vessels going through the skull
to the cranial sinuses is materially diminished. The expedient of indi-
cating on the bone itself the site of the trephine centre is also of some
importance. The careful outlining of the region to be explored on the

1 As tliU inuBfi through tho printer'* hand*, the Lancet of April 7, 1888, report* a ease of cerebral
tumor operated on by Mr. F. A. Heath, iii which, though the tumor wax not removed on account of
adhesions t<> the anterior fossa, the benefit derive. 1 from the relief to the pressure effects* was most de-
cided. "The i»itient recovered promptly from the operation, with the formation of ■ hernial protru-
sion of the brain under the healed sculp, and shortly afterward regained a considerable power of

'""' in the paretic limbs and remained free from epileptic attacks for over two months and for a

long time was rid of the headache, lie was seen thirteen months after the operation, and, though com-
pletely blind, could walk about very well. Of late, the headache had returned and the epileptic attack*
had BOOTH more lie.|uent."

In tho same Journal is the report of the post-mortem of a tumor situated on the auditory nerve, and
with it is the comment of Mr. Vi-tor Horsley that it might have l>ecn removed by an operation which
lie bad recently adv.x-ated, of inciting the tenbn iiim and ligating, If necessary, the lateral sinus. My
o» n oI.scm., lions, recorded elsewhere, have shown that the sinus can l>e lifted out of the way without
difficulty, by raising up tho dura, and a previous ligation of the longitudinal sinus leads me to believe in
the powMMt) Of doing the same with the lateral sinus, as indicated by Mr. Horsley. I have exposed acci-
dentally this latter sinus in *everal instance* and also wounded it without harm. (See "Remark* on
the Surgical Treatment of Drain 8uppuration following Ear Disease," Medical Record, April 9. 1887.)

WEIR, SEGUIN, CEREBRAL SURGERY. 229

shaven scalp is of no avail after this has been lifted away, and the
plan suggested in the history of the present case answered its purpose
very well.

// opening should be a large one. Horsley applies the two
inch trephine, which I now exhibit, in two places and then cuts away
the intervening ledge of bone. Lately he has used, as did Graeme
Hammond, a dental or electrical bone-cutter, which permits greater
rapidity in work. The enlargement with the rongeur after the removal
of two or three buttons of bone can, however, be quickly done by a
muscular surgeon with Luer's or Robert's rongeur forceps. Not only is
a large opening required for the removal of a growth, and they have
been extracted successfully over four ounces in weight and as large as
an apple, but it is required for exploratory purposes. It must be re-
membered that many times the surgical interference is entered upon
with this view alone, and as the localization cannot always be perfectly
made out, a considerable portion of the brain should be exposed to pal-
pation and sight. I said purposely brain and not dura, for I cannot
but think it a faulty procedure to refrain from opening the dura mater
after cutting through the skull, and believe that the accuracy obtained
by lifting up this membrane more than compensates for the supposed
additional risk. I venture also to condemn or to belittle the practice of
making a diagnosis of a tumor by penetrating with a needle through
the unopened dura. Even after the membrane has been cut through,
the help obtained by such a procedure is, I think, extremely small. A
tumor too soft to be detected by the finger will not be recognized by
the needle. Moreover, I can hardly consider the needle a perfectly
safe instrument to use in the soft tissues of the brain, for in two in-
stances it has come to my knowledge that a fatal hemorrhage has fol-
lowed its use. Hence, after the exposure of the brain, if its surface be
markedly bulging, which is always abnormal, or if by its loss of pulsation
or by a marked change in color it does not indicate the presence of a
tumor, solid or fluid, then the surgeon should, by gentle but firm pressure,
palpate the bared convolutions, and he can even insinuate the pulp of his
finger under the bony edge of the opening to a short distance with safety.

I have elsewhere (Medieal Xews, April 16, 1887) stated that in regions
traversed by important bloodvessels, as, for instance, the longitudinal
and lateral sinuses, that after the skull above them had been gnawn
away they can be lifted from their places and drawn aside without
risk by pulling upon the dural flap, and in this way the median plane
of the brain or the tentorium could be brought fairly into view. The
attached base of the flap, I need hardly say, when near a sinus, should
be toward the bloodvessels.

The objection that has been raised by Bergmann, and previously
alluded to, against the attempt to remove large tumors of the brain,

230 WEIR, SEGUIN, CEREBRAL SURGERY.

because oedema of this organ would rapidly result from the sudden with-
drawal of pressure, is neutralized by the generally conceded innocuous-
ness of large cranial openings, whether produced by the surgeon or by
accident. The permanent loss of protection, more hypothetical than
real, that follows the taking away of a large portion of bone is, how-
ever, met by the replacement, at the termination of the operation, of the
fragments of bone, which procedure was first taught us by MacEwen, of
Glasgow, and which has been followed with only very moderate success
by Horsley.

This end is much more satisfactorily accomplished by carefully pre-
serving the disks of bone, removed by the trephine, in towels or cloths
wet with an antiseptic solution of carbolic acid, 1 : 60, and kept warm
during the operation by immersing the vessel containing them in warm
water. They can, after the dura mater has been closed at the comple-
tion of the operation by sutures, be replaced and any gaps between them
can be filled by the chopped-up fragments that may have been produced
by the rongeur or chisel in further augmenting the size of the cranial
aperture. In this way I have, in one of two instances, replaced two
buttons of a one inch trephine, and in the other, three buttons of the
same size, and accomplished an almost complete bony closure of very
large openings. In neither instance has any necrosis followed.

I had conceived myself original in this application, but have learned
to appreciate more than ever the truth of the old adage, that " there is
nothing new under the sun," since it has been brought to my attention
that Clarke, of Glasgow, employed the same method in 1886. Its merit
and ease of application, however, I must insist upon.

Hemorrhage. Hemorrhage from the bone itself may be troublesome
and require the ordinary methods of pressure, or of plugging or, better
still, of crushing the edges of the opening by blunt forceps to control it.
Bleeding from vessels of the dura mater, for instance from the branches
of the middle meningeal, may be controlled by catching them up with
a tenaculum and tying the included vessels and membrane, a plan which
was carried out in the case already presented. It' the bleeding comes
when the dura is divided, the open vessel can be caught with the cut
edge of the dura, with the ordinary artery damp and secured by • liga-
ture. Vessels of the pia mater are easily torn and are oftentimes
troublesome to secure, tearing readily under the traction of the forceps,
even though delicately held. It is better to secure them by meant ef

the tenaculum, and to tie the ligature with equal traction of its end.-.
[f one is careful bo incise or tear the pia when no vessels are to In-
seen, one can lift this membrane from the convolutions, and in this way
obtain a clear field for further operative work. Any vessel of size in
the brain substance itself or in the depths of the convolutions should
be seized and secured, however far in it may be. The ligature may not,

WEIR, SEGUIN, CEREBRAL SURGERY. 231

however, always he practicable. In my first case of cerebral tumor, in
which the hemorrhage, which recurred after being checked at first by
pressure, was probably from a branch of the posterior cerebral artery,
it would have been difficult, if not impossible, to place a ligature on it.
It could, however, have been controlled by the use of a clamp which
might have been left to project through an opening in the flap for a
period of from twenty-four to forty-eight hours, and then safely dis-
engaged.

the removal of the tumor, it is often necessary to cut through a
certain thickness of brain tissue. This is also the rule, I may state, in
connection with cerebral abscess. In several of the cases, however, the
tumor was superficial and presented itself to view upon the raising of
the dural flap. When the tamor is not strictly superficial, it can, after
being recognized by palpation, be reached by an incision, or by gently
tearing through the cerebral tissue by means of the end of the finger or
by a director. The handle of a spoon will serve then very satisfactorily
to aid in its extraction, though my last experience with the use of Volk-
mann's blunted spoon, which was guided by the finger introduced to the
tumor, was a very happy one. However, in using such a shaped instru-
ment, the edges should be carefully rounded.

Drainage and cloture of the wound. Drainage of a wound made in
the extraction of a cerebral tumor is just as important as in any other
wound. It has long been a recognized fact after injuries, but only re-
cently, however, after the extraction of tumors, that the cavity left in the
brain does not leave a permanent gap with vertical sides, but, as Horsley
states, the floor of the pit bulges up in a very short time, even almost to
a level with the surrounding cortex. In addition, the cut edges become
slightly everted, and if less brain than bone is removed, they are extruded
into the opening of the skull. After having ascertained that all hemor-
rhage is checked, and nothing but pressure and the ligature or the
clamp should be used to accomplish this, the drainage is provided for
best, in the use of a small, duly perforated rubber tube. This should
emerge at the most dependent position of the wound and should
reach the bottom of the cerebral cavity. It should be removed, accord-
ing to Horsely, in twenty-four hours. But I have thought, as in
operations elsewhere, that there is a little less risk of infection to the
1'avorably progressing wound by the process of dressing, if the removal
of this tube is left to the end of the second or third day. Especially do
I so act in a case which is progressing favorably. The raised flap of dura
mater is, after the insertion of the drainage tube, replaced and sew n
together with fine catgut sutures. I have omitted to state that in cut-
ting this flap it is well to keep from one-eighth (Horsley) to one-fourth
of an inch, and preferably the latter distance, from the opening of the
bone, otherwise there will be difficulty in applying the sutures when this

232 JACOBSON, TONGUE CANCER.

replacement is desired. The disks of bone and bone fragments are now
put in situ, the wound finally bathed with the antiseptic solution and a
few strands of horsehair or catgut placed among the bone fragments to
emerge alongside the drainage tube, and then the flaps of scalp, after
having first taken off the rubber hemostatic bandage encircling the
head and securing whatever vessels may now bleed, is likewise replaced
and duly sutured with catgut. Over all this a sublimate antiseptic
dressing should be applied with iodoform dusted over the layer resting
upon the wound. Finally, it is better to keep the head somewhat
elevated for a few hours after the operation, which latter, it is need-
less to state, should be accomplished under the strictest antiseptic pre-
cautions throughout, even, to my mind, resorting to the protection of
the spray, the efficacy of which cannot be doubted while its inconve-
niences must be admitted.

SOME REMARKS ON TONGUE CANCER, AND THE CHIEF
OPERATIONS FOR ITS REMOVAL.

By W. H. A. Jacobson, M.A., M.B., M.Ch. Oxon., F.R.C.S.,

ASSISTANT SURGEON TO OUV's HOSPITAL; SUBQEON TO BOY A I. HOSPITAL rOB
CHILDBEN AND WOMEN, LONDON.

With reference to two or three very practical points which rise up
with every case of tongue cancer, it must be remembered that this is a
form of cancer which is very frequent and is increasing in frequency : '
one which attacks all ranks of life, which, after its early stages, is espe-
cially malignant,1 and one in which, finally, an operation seems to be as
much dreaded and deferred by men, as one for carcinoma mammae is by
women.

A Pkh-cancerous Stage.8 — However tongue cancer begins, it passes
through a pre-cancerous stage — L e., a stage (the duration of which is
unknown and varies extremely) in which inflammatory changes only
are present, any ulcerative and other changes in the epithelium which
may be present not amounting, as yet, to epithelioma, but on which
epithelioma inevitably supervenes. The boundary line between this

* Amoiignt i iMiimon cancers— «. g., of breast, rectum, uterus, etc., cancer of the tongue stands about
third, although so rare in women. Mr. Marker, in his carefully worked out article on Diseases of the
Tongue (System of Surgery, toI. ii. pp. 67, 78), give* a aeries of tables showing that in the last
thirty years there has been a steady increase from 2.6 to ll.fi per cent.

* This is shown in the following facts : (a) The rapidity here is quite different from other epitlu-
liomata Epithelioma, usually thought a slow cancer, here, in a moist warm cavity, much irritated,
and never dry and warty, is terribly rapid. (6) Gland invasion is here not only certain, but inevitably
early as well.

* Mr. Hutchinson thus named this stage and pointed out its Importance.

JACOBSON, TONGUE CANCER. 233

pre-cancerous stage and cancer is extremely narrow; the duration of this
may be, and often is, extremely brief.

Aids in recognizing this stage are: (1) the duration of the ulcer;
2 its obstinacy to treatment; (3) the age of the patient; (4) absence
<>f any duration or fixity; (5j careful scraping of surface of sore and
microscopic examination.1

In doubtful cases, after cleaning the surface, we should scrape lightly
with a spatula or blunt knife and examine the result microscopically.
In a sore not yet epitheliomatous, the epithelium is still regular,
squamous, flattened, the nuclei small and single. In an ulcer becoming
epitheliomatous, the cells are no longer regular, but variable in shape
and size, oval caudate instead of square, with nuclei large and multiple.
X.>t infrequently cell nests or fragments of cell nests may be found.

Questions Arising before Operation. — The operating surgeon
will often be called upon to give an answer to the two following ques-
tions : ( A) Will the disease be permanently cured ? (B) If a permanent
cure is impossible, will life be bettered and prolonged?

(A) Will the disease be permanently cured f Really permanent cures
are, as yet, too few — ten per cent, of cases operated on according to
Barker,' or thirteen per cent, according to Butlm" — to afford a satisfac-
tory reply.

The explanation of this is not altogether to the credit of our profes-
sion. Patients and we alike are too often both to blame. The gravity
of the disease is overlooked, the time of the pre-cancerous stage is lost.
Because tongue cancer is so often preceded by syphilis or local irritation,
the practitioner diagnosticates the one or the other and suggests it as
the essential part of the mischief. " Give drugs another chance " — e.g.,
potassium iodide, potassium chlorate, mercury, caustics. To these there
are, in nearly every case, the strongest objections in the pre-cancerous
_re. Time is lost, strength is lost aud the patient is lulled and be-
fooled, while all the time the vascularity and irritation around the ulcer
are increased. Furthermore, the patient is in part responsible for the
delay, as he very naturally dreads the- operation, exaggerating its
danger, pain fulness and the supposed inevitable loss of speech. These
delays lead to "cultivation of cancer "and to miserable deaths.

We shall never be able to combat successfully these causes of delay
until (1) the importance and value of the pre-cancerous stage are recog-
nized. (2) Getting cases of tongue cancer early,4 we are enabled to

1 Butlin (Sarcoma and Carcinoma, p. 154, Plate IV., Figs. 1, 2 and 3). The use of cocaine will,
ii '»'.idayn, facilitate the above examination.

» Loc. cit., i

* Diseases of the Tongue, p. 295. Mr. Butlin's percentage is calculated from seventy cases. He is
inclined to doubt whether a larger number of cases would afford so good a percentage of recoviri. ».

4 If ulceration has been persistent for longer than three months, permanent recovery is very doubtful
If it has pwsastod for over six months, if more than one-third of the tongue is iuvaJed, if the floor of
the mouth is involved, permanent recovery is well niph certainly hjpeleas.

VOL. 90, NO. 3.— SEPTEMBER, 1888. 16

234 JACOBSON, TONGUE CANCER.

assure the patient that removal of one-half of the tongue will be suffi-
cient, and that the other half can be safely and usefully spared to him.
It has been denied by some that leaving half the tongue is attended by
any good result. From an experience of twenty-two cases of removal
of the tongue, I am able to say positively that a patient, in whom the
tongue has been split longitudinally and half removed, has, in the half
which is left, a member which most usefully represents the tongue, and
over which the patient has, in spite of what is said to the contrary, most
serviceable control.1

(B) If a permanent cure is impossible, will life be bettered and pro-
longed t Cases which are not operated upon die within eighteen
months, many in twelve months. An operation wisely plauned and well
carried out often gives a gain of six or eight months. This is a gain
not only of time, but also of comfort. Death by glandular recurrence
in the neck is less painful and noisome than death by mouth cancer.
No one who has seen much of tongue cancer will have any difficulty
in answering the question : which of the two is the more painful to the
patient and distressing to those around him, tongue cancer, with its
horrible fetor, profuse and foul salivation, its agonizing pain, its racking
earache ; or recurrence in the cervical glands, an alternative in which
the patient is often able to work up to near the last and, until toward
the close, is free from the agonizing tenderness, the stinking fetor, the
dribbling of foul saliva and the slow starvation day by day of tongue
cancer. When an operation is certainly attended with risk, the patient
in facing it may be relieved by the assurance that a life prolonged in
hideous misery and constant agony is worse than death following close
upon an operation.

" When a man has only, suppose, two or three years to live, it is no
small advantage if at least half the time can be spent in comfort rather
than misery, and in profitable work rather than in painful idleness "
(Paget). If a patient cannot make up his mind to an operation and is
losing precious time, he should be warned, without being unduly fright-
ened, of the state of things which will inevitably follow, alluded to a
few lines above. Usually as soon as this sets in, as soon as the condi-
tion of the tongue renders him a nuisance to himself and others, with
the disgusting fetor, the constant dribbling of foul saliva which cannot
be swallowed, the weary aching day and night lit up into agonizing
flashes when the parts are touched or moved, t he patient becomes willing
to run any risk. But too often by this time not only are the glands
already enlarged, but the mischief has reached the floor of the mouth
or the alveolar mucous membrane by extension, though not yet, perhaps,
with ulceration.

I In a patient from whom I rein..T.'il half lh.' tongue two ami one-half year* ago, the hypMtropfej
of the remaining half it very marked and the apeech excellent.

IACOBSON, TONGUE CANCER. 235

OPERATIONS. — The following four will be considered here as giving a
choice which will meet all eases, viz.: 1. Whitehead's. '2. Symes's. 3.
K cher's. 4. Keraseur.

With these certain aids — e. g., slitting the cheek, preliminary laryn-
uiy and ligature of the Unguals, will also be considered. One or
two other methods will then be briefly alluded to.

While the above operations, and I allude especially to the first three,

give a choice which will enable the surgeon to meet any case of tongue

cancer, whichever is chosen must be completely carried out ; " niggling "

operations lead inevitably to return and accelerated growth in the

ie itself.

1. Whitehead's Method.

The advantages of this are very great. • They are :

A. The transverse section of the body of the tongue can be placed
deliberately well behind the growth. However far behind the growth
the loop of the ecraseur is placed before the operation and however
securely it seems to be retained in situ by large curved needles, as the
loop is tightened, owing to the enormous strain which is gradually
applied, the needles and the loop are forced forward nearer and nearer
to the growth. Now the neighborhood of this is all ready to become
the seat of malignancy. All around the growth the epithelial columns
are ready to dip down into the vascular connective tissue beneath, on
which, in health, they never encroach. Again, the parts around are
loaded with inflammatory cells, soft and vascular. If, as is very likely,
owing to the tremendous tension to which it is submitted, especially
when the parts are very soft, the loop comes crushing into this neigh-
borhood and makes the section here, the indipping processes, which
extend for some distance around the actual epithelioma, may, owing to
the vascularity and inflammation consequent on the operation, break
out into speedy recurrence. Again, the insertion of the needles, which
are intended to keep the loop well behind the growth, is not always an

matter, especially if the growth is far back and if the front teeth
are well developed, whilst the molars and premolars are too deficient to
allow of wide opening of the mouth with a gag.

B. The resulting wound is very clean, there being very little lacera-
tion and no charring. The slight decomposition which may take place
from an extensive operation, even with scissors, is readily checked by
the use of iodoform and ether. The advantage of this, in savin i
patient whose vitality is already lowered from the depressing effects of
being liable for days to breathe and swallow with a fetid sore in his
mouth, in securing rapid granulation and healing and thus enabling
the patient to be early propped up and soon to leave his bed, must be
obvious to every surgeon who knows how great the risk is of fatal septic

2-36 JACOBSON, TONGUE CANCER.

bronchitis in these cases. For the same reason secondary hemorrhage
is unknown.

C. The instruments required are extremely simple and few, as will be
seen from the account of the operation.

The Operation. It is most essential that the anaesthetic should be in
the hands of a man who can be thoroughly trusted. It is often taken
badly in these cases, with much dyspnoea and restlessness at first and
during the operation ; owing to the open mouth admitting much air and
the fear of interfering with the operation, the patient often " comes to."
The only thing is to get the patient well under at first ; later on
it will be well not to keep him too much under the influence of the
anaesthetic, in order that, the sensibility of the larynx being retained, the
blood may not enter the air-passages. The administrator must watch the
tint of the lips, the condition of the veins in the cheeks, and should know
when a little blood is only safely, though noisily, bubbling at the back
of the fauces and when it is getting into the trachea. I look upon the
administrator of anaesthetics, in these cases, as quite as important as the
operator. Two reliable assistants who understand the steps of the opera-
tion are needed, one to take the gag in charge and to sponge when
needed and the other to hook back the corner of the mouth with two
fingers while he is ready to sponge and thus, with the position of the
head over to this side, with the aid of deft sponging, enable the blood
to escape freely from the wound into the cheek and out of the mouth.
Two nurses should be ready to supply sponges ; these being absolutely
(Kan, soft and thoroughly wrung out of iced Condy's fluid and firmly
secured on holders. The following instruments should be close to the
operator's right hand: scissors, a pair of torsion forceps and Spencer
Wells's forceps, a needle in handle, threaded with stout silk and one or
two medium-sized ligatures of carbolized silk.1

A good light is absolutely essential : daylight, with the operator close
to I window, being the best. If it is needful to operate when this cannot
be obtained, as in a succession of foggy November afternoons, a good
lamp li.Lrlit concentrated by a laryngeal mirror will be useful. In making
arrangem* qui for a good light, the surgeon will remember that, while the
removal itself takes but a short time, getting the patient under the
anaesthetic and keeping him under its influence often render the opera-
tion much prolonged. It may not be superfluous to add here that thi>
i- an operation which calls for coolness and decision on the part of the
operator and for promptness with their help on the part of all those
who assist. No crowding on the operator.no obstruction to the Light
by b; should be permitted for a moment

' Mr W ini.l.in.1, h.-Hrinn that I had twin- «>|>erMoil by his method, in 1881, kindly sent me * pair of
«..r.-. Tli.y uir ruth.r longir than the ordinary scissors, perfectly flat, Tory sharp up to the
tips, which are square aud blunted.

JACOBSON, TONGUE CANCER. 237

Preliminary laryngotomy. The question of the advisability of this
operation now arises. It forms no part of a " Whitehead " proper.
The operator who introduced the scissors-method, and whose success
with it is so well known, never, I believe, uses a preliminary laryn-
gotomy. In my first six cases I followed him closely. In the later
sixteen I performed laryngotomy on several occasions, though I fear
Mr. Whitehead will consider this admission on my part as a sign of
" falling away." With a wider experience, I am led to think vcry
lightly of this preliminary step, and of the plugging at the back of the
mouth, which it renders safe ; and I do so for this reason : with the
fauces plugged and the patient breathing through a laryngotomy canula,
the surgeon can neglect the hemorrhage more, can operate more deliber-
ately and thus (and this is the value of this preliminary step in my
mind), at every step of the operation, can have the parts more thoroughly
sponged dry and thus be enabled throughout to keep more surely
wide of the disease. In other words, I do not dread the hemorrhage
which accompanies a scissors-operation for itself, but because it is liable,
in spite of careful, prompt sponging, to obscure the field and thus lead
to cutting dangerously near the growth, a danger especially likely to
happen if the hemorrhage is at all free, if the parts cut are very much
softened and if the patient is not taking the anaesthetic well.

For these reasons I am inclined to recommend a preliminary laryn-
gotomy, with plugging of the fauces in these cases: 1. When a surgeon
who values Whitehead's operation is doubtful as to his means of meeting
hemorrhage. 2. When the growth extends beyond the middle of the
tongue into the posterior third. 3. When the floor of the mouth is at
all involved. In growths limited to the anterior half of the tongue,
unless there is much fixity, laryngotomy is not needed, for, as will be
subsequently seen, sufficient of the tongue in such cases, after very little
use of the scissors, comes right out of the mouth.

If it is decided to perform laryngotomy, this operation is done and a
soft clean sponge, dusted with iodoform, is tied with silk into appro-
priate size and fixed at the back of the fauces, the silk being brought
out of the mouth and held by a finger of the assistant who has charge
of the gag. This sponge must be pressed well back and care taken
that it does not draw back and down the base of the tongue, or it may
cause some difficulty in securing the linguals when the transverse section
of the tongue is made far back. The anaesthetic is now given through
the tube, an additional advantage brought about by the laryngotomy, as
the administration of the anaesthetic does not interfere with the field of
operation. So very little sloughing and swelling of parts follow on Mr.
Whitehead's operation that the laryngotomy tube may be removed as
soon as the patient is back in bed and has " come to " comfortably.

Whether laryngotomy is performed or not, the patient, being propped

238 JACOBSON, TONGUE CANCER.

up, is brought quite to that side of the table on which the surgeon
stands. A gag1 is placed on the side of the mouth opposite to the
growth and the mouth widely opened. The tongue is then transfixed
on the diseased side, well back in its anterior third, wTith a needle in a
handle loaded with stout silk ; this is looped and knotted and the tongue
thus well drawn out of the mouth. The surgeon then, with a sharp-
pointed bistoury, splits the tongue longitudinally along the raphe to a
point thoroughly well behind the growth. This is another departure
from a strictly performed " Whitehead," but it has the following advan-
tages, while it causes no troublesome hemorrhage if the blade be kept in
the middle line: 1. If the whole tongue is to be removed, it places the
hemorrhage much more under the control of the surgeon, as he can deal
with each half separately and with one lingual securely at a time. 2.
It enables the surgeon to leave half the tongue if he finds it safe to do
so. It has been said that leaving half the tongue is useless, the part left
being but little under the patient's control. I am of an opinion entirely
different. In cases in which I have been able, after splitting the tongue, to
leave half of it, the part was most useful both in speaking and swallowing,
etc.,2 and I am, further, most strongly of opinion that if patients could
be assured that only half of the tongue would be removed, they would
submit much more readily to an operation they dread so peculiarly and
to the grievous putting off of which is due the very small percentage of
permanent cures.

The tongue having been split and the diseased half drawn well out of
the mouth, the surgeon next divides with scissors the mucous membrane
between the tongue and the alveolar process, keeping close to the bone,
so as to be wide of the disease. The anterior pillar of the fauces is
next divided. While the above steps are taken, the two assistants
sedulously sponge away any hemorrhage into the hollow of the cheek
and out of the mouth, the cheek being retracted as already directed.
Careful sponging and sponge pressure on bleeding points are most essential
if the surgeon is to cut wide of the disease.

If the disease has implicated the frnenum and its vicinity, two or three
bfl lower incisions should be made, so that the scissors may be intro-
duced on :i level with the disease. If this is not done, the scissors have
to he dipped in over the teeth in an awkward way and one which, It
soon as the bleeding occurs, makes it impossible to he sure of getting
below the disease. The scissors can be introduced with much greater
facility and used to much better purpose, if a gap is made in the teeth ;

> Of thrw I prate Krohne <k Seseman's modification of Mason's gag, as the best all 'round instru-
iiinit!.. It wu« Him brought to nij not i., iv im. Bewttt, whohai found it the readied and n
Id case of m>«M in tin- :idiiiini.«tratinn of Mlltlntlfl 111 8 "".m's gag is also a good om\ l>nt I linv,>
found it slip occasionally in spite of its lligenion- inr. ImiiUni. W« Mill need a gag M .lous

Jaws.

JACOBSON, TONGUE CANCER. 239

these can be kept and fitted to a plate later on by a dentist. When
half of the tongue has been freed all round, the muscles between it and
the floor of the mouth are cut through with a series of short snips, until
the diseased half is separated on the level of the lower part of the jaw,
ar back as is needful. During this stage, oozing will take place and
one or two small arteries will jet with varying freedom in different cases,
l)iu these will yield to pulling steadily on the tongue and to firmly
applied sponge pressure.

The tongue having been freed horizontally up to a point well behind
the disease, the transverse section is now made, and here I have found
the following precautions useful. Instead of cutting straight across the
half and trusting to being able to rescue the lingual on the face of the
stump, a step by no means always easy of accomplishment, owing to the
artery being often at once obscured by a small pool of blood and to the
not infrequent softness of the tissues in these cases, I cut a deep groove
through the tough mucous membrane of the tongue and tear through
the softer muscular tissue with the closed scissors or a steel director, until
the lingual nerve and artery are seen ; then, having applied a long-bladed
pair of torsion forceps to the remaining tissues, cut away the half of the
tongue in front of the forceps and then twist or tie the lingual artery
which has thus been secured.1

If it be needful, the surgeon then proceeds to deal with the other half
of the tongue, a step which is much facilitated by the room given for
manipulation by the removal of the first part.

S/ltfin;/ the cheek. This step is an excellent one. It may be made use
of in (."uses in which the disease is situated very far back, extending close
to or on the anterior pillar of the fauces, in which the hemorrhage is
exacted to be especially free, in which the light is unavoidably very had
or in which there is unusual difficulty in getting the jaws well apart.
The cheek is slit as far back as the anterior border of the masseter, the
facial artery and other small branches being secured at once. The parts
require most careful adjusting afterward, especially at the corner of the
mouth, where, from the dribbling of saliva, primary and exact union is
not always secured.

iminary ligatvare of the Unguals. This step has been very largely
practised by Dr. P. Billroth.* Unfortunately, he expresses no opinion
as to its value. He states that he ligatured the artery twenty-seven
times I apparently in all as a preliminary step), but only adds that no
secondary hemorrhage ever followed and that the wound always healed
satisfactorily.

1 If any difficulty occur in dealing with a divided lingual, especially if the tongue has been divided
far back, a suggestion of Mr. Heath's will be found most useful, viz., to hook one or two Augers into
the pharynx over the stump of the tongue and to draw this forward, thus at once arresting the hemor-
rhage by pressure and bringing into view the bleeding point.

* Clinical Surgery, Syd. Soc. translation by Mr. Dwt, p. I1&

240 JACOBSON, TONGUE CANCER.

Dr. Shepherd, of Montreal, has recorded1 three cases in which he tied
both linguals previously to excision of the tongue, which operation was
bloodless.

I have never taken this precaution myself and I do not recommend it
for the following reasons: (1) In three cases in which I know of this
precaution having been taken, the hemorrhage was as free as in the
usual operation with scissors performed without any such preliminary.1
(2) I think that an experience derived from operations in twenty-two
cases justifies me in saying that if the operation with the scissors be per-
formed with attention to the details given above, the hemorrhage is not
so difficult to deal with as to require this precaution.3 (3) The ligature
of both linguals is by no means an operation that can be done quickly
and is one that requires a good light. It may thus take up a good deal of
the time required for dealing with the disease of the tongue itself. If it
be answered that diseased glands can be dealt with at the same time and
by the same incisions, I must state, in no contradictory spirit, that I am
of a distinctly contrary opinion. Removal of the epitheliomatous glan<ls
requires of itself much time and painstaking, lying, as they do, in long
chains and in relation with most important structures. If they are to
be removed with that thoroughness which alone justifies any attack on
them, this should be done with the full allowance of time and the undi-
vided attention which are given by a separate operation, either before
or after that on the tongue.

2. Symes's Operation.

This consists in dividing the symphysis menti and then removing the
whole tongue and floor of the mouth with knife or scissors, or partly
with one of these and partly with the oeraseur. It is a far more serious*
operation than the one already described, and often involves prolonged
after-treatment, owing to the tardy union of the jaw. It should be re-
served for those cases in which the ulcer involves the floor of the mouth
or in which, in addition to an ulcer on the side, a hard mass of
infiltration can be felt in the substance of the organ. When this
operation is contemplated in an aged or broken-down patient, every
attempt should be made to improve the general health previously. An

1 Aiin.il- ■■! Nil • iv. N.iwmli.T, I--..V Mr. TlWTM (LMM t. \pril J'J. 1 ss:'. 1 publishes four cases of

nmmI i t tii. t nga*, in wind, llgainri of Um Uagnali «•** resorted to, The B«morrh*g* which fol-
lowed ibr n|M-mtl<>ti mi th<< toiiKDK 1^ -uti' i !,, ii.ivc t*>«>n " very inalgoiflauil ami moally Immediately
arrested t.y In* jnmm wKfc ■ moag*; it kienhj fur back in the ragtoa of the tonsil that any fchwJIm
may occur that doea not ceaae almost apontane

* The operations were h.n- pattern**1 hj two *f my DOllen^u. -. .in. I tliere could !><■ no ilonht that the

■ajaali wan new <\.

* In writing thai I am tnkiue it for (natoi th.it Um mrgooawfll b* ■IM by helper* as apt and

tetaamta Maomjk to nn.i
4 Lane M . nmi il. p. l«8 See also tho account „f I>r. FMdea of his otto, K<linl>.

Mrd f of the seTerity of this operation, both of Prufe—or 8ym**** tot

two patient* *1 i •-. 1

JACOBSON, TONGUE CANCER. 24 L

aiKtstlu tic being given and a preliminary laryngotomy performed, the
patient's head and shoulders are raised and the surgeon divides the soft
parts of the chin as far down as the hyoid bone, if the soft parts in the
floor of the mouth are much implicated. The vessels being secured,
the jaw is drilled below the teeth a quarter of an inch on either side of
the middle line and then sawn through.1 A sponge is now placed at
the back of the fauces and, the halves of the jaw being forcibly retracted,
the tongue is well drawn out by a loop of silk, the mucous membrane
snipped through between the tongue and the alveolar process and the
anterior pillar cut through. The genio-hyo-glossi and genio-hyoids are
next divided,7 and the tissues in the floor of the mouth separated as
deeply as necessary with the scissors or blunt-pointed bistoury aided by
the finger, partly by cutting, partly by tearing, any vessels that require
it being tied or twisted. The tongue being thus freed laterally and
below as far back as is needful, the transverse section is made one-half
at a time, with the precaution already recommended.

The floor is now carefully inspected and any suspicious patches or
enlarged glands most carefully removed. In raising the former before
using the scissors, a tenaculum is often very useful. If it be preferred,
though I in no way recommend it, as soon as the attachments of the
tongue to the floor and sides of the mouth are sufficiently divided, the
transverse section can be made with an ecraseur, the loop of which is
slipped over the tongue and kept in position by two curved needles.

The two halves of the jaw can then be wired, but to promote speedy
union a cap of vulcanite or silver had best be fitted on to prevent dis-
placement of the fragments. A drainage tube should be brought
through from the mouth to a point just above the hyoid bone, before
the soft parts are united with sutures. In some cases it may be needful
to secure the stump of the tongue forward by a loop of silk fastened to
the cheek by strapping.

3. Kocher's3 Method by Lateral Infra-maxillary Incision.

This operation, like the last, is a severe one; it also opens up freely the
connective tissue of the neck. It has the great advantage of enabling
the surgeon to deal with mischief far back in the tongue and at the
same time of removing enlarged submaxillary glands. Furthermore,
it can be performed antiseptically. The mouth being disinfected with

1 By some it is advised to saw this somewhat angularly instead of vertically, to promote interlocking
and uniun of the fragments ; as, however, necrosis may follow this as well as the other form of bone-
section, the longer time that it entails is scarcely worth giving.

* If only "in-half of the tongue need removal (a rare contingency in cases which call for this opera-
tion), the complete separation of these muscles and the consequent danger of the falling back of the
tongue will alike be avoided.

3 Dent Zeitwh. f Chir., Dd. xiii , 1880 Mr Barker was the first, I believe, to draw the attention
of English surgeons to this operation (Diseases of the Tongue. System of Surgery, vol. ii.).

242 JACOBSON, TONGUE CANCER.

1 in 1000 perchloride of mercury solution and a preliminary laryng-
otomy performed, an incision is made from just below the symphysis
down to the hyoid bone, following the digastric muscle back to the
anterior edge of the sterno-mastoid and then up to near the lobule of
the ear. The flap thus marked out of the platysma and fascia? is then
turned up and the facial artery tied. The submaxillary region is
then thoroughly cleaned out and the lingual artery secured on the hyo-
glossus. By cutting through the mylohyoid muscle, the cavity is now
opened into and the tongue brought out through the wound and divided
as far back as is needful, one-half being removed after splitting the organ,
or the whole tongue removed, the opposite lingual being tied in the neck
if needed.

The large wound is then carefully packed with strips of antiseptic
gauze, a drainage tube being first inserted. The patient continues to
breathe through the laryngotomy tube until the wound and mouth are
quite sweet and thus the risk of septic broncho-pneumonia is lessened.

If it be desired to conduct the operation as strictly antiseptically as
possible, before it is begun plugs of salicylic wool must be placed in the
nose, the cavity of the mouth well washed out with 1 : 2000 mercury
perchloride solution and the spray used at the operation and at each
dressing. As, however, it is impossible to render aseptic the closely
contiguous cavities of the posterior nares and pharynx and as the
patient will require feeding at regular intervals with a nasal tube, the
writer would prefer to trust to sufficiently frequent changes of the gauze
with which the wound is plugged, dusting on iodoform and powdered
boric acid, painting on with a camel's-hair brush iodoform and ether
and securing free drainage by a tube which has one end brought out of
the mouth and the other at the lower and posterior angle of the wound,
li >th lodged in aseptic dressings.

4. The Ecraseur.
This may be used in different ways: t lie two following are the chief

(1) Through the mouth in combination with scissors, a method mod
by Mr. M. Baker.1

By meani of a puncture in the submaxillary region or through
a wound which has to be made here in the removal of enlarged glands.

If the Ecraseur has to be made use of, the first method is by far the
simplest and sp.rdi<-t way of using it. In addition to the instruments
already given in the description of the operation with scissors, the
surgeon must be provided with a stout, short ecraseur, curved on the
flat, working smoothly and carrying a strong loop of whip cord.1

> Use*, April in, IMQ, Ki,ti..tmry of Surgery, vol. li.
f wire 8oe the next Ibotoota

JACOBSON, TONGUE CANCER. 243

The first part of the operation is much like that already given. The
_rue being well drawn out with a silk loop, the anterior pillar and the
mucous membrane between the alveolar margin and the tongue being
cut through, the tongue is then split with a bistoury along the raphe1 as
tar back as it is needful and its attachments to the floor of the mouth
partly snipped through with scissors, partly torn with the finger. The
tongue being now freed sufficiently to make the transverse division, two
slightly curved needles in handles are made to perforate the tongue a
full inch behind the posterior limit of the disease and the loop is then
slipped on and adjusted behind the needles. Before doing this, the
writer would strongly urge the recommendation already given, that a
groove be cut with the scissors through the mucous membrane of the
dorsum and sides of the tongue. This simple step will serve to steady
the bite of the ecraseur and lessen the risk of its gradually coming,
■a it ii tightened, dangerously near the growth, and it will also shorten
the time that the loop takes to effect its work. When first adjusted,
the ecraseur may be worked more quickly, but as soon as real resist-
ance is felt, the screw must be turned more slowly, a half or three-
quarters turn being made every minute, or at longer intervals if the
loop seems to be cutting too quickly. It should always be remembered
that if oozing takes place from hurried use of the ecraseur, it will be
for more difficult to arrest on a surface bruised by this instrument than
on one cleanly cut by scissors.1 If the whole tongue is removed, the
■^eur should always be applied to each half separately. Making the
transverse section across the whole tongue at once is most tedious, and
the great strain is likely to be too much for the loop or instrument
itself. It also causes the constricted tongue to swell into a large livid
mass which much obstructs the breathing, and, if as is likely, both the
Unguals, which are left to the last, are divided simultaneously, the
furious spirting of these vessels in two crossing streams is most embar-
:i)g.
I do not recommend the use of the ecraseur for these reasons :
(1) However well behind the disease the loop is placed (a step by no
means easy to secure when the disease is situated far back), as it is slowly
tightened it tends to come forward (even when a groove has been cut
in the mucous membrane), gradually grinding the needles placed to
keep it in position and the loop closer and closer upon the diseased
area; or, if not actually into this, into one from its close contiguity
ready to take on disease.

> Mr. Butlin (Disease of the Tongue, p. 334) gives the following case : " The only instance of death
from hemorrhage in my table occurred in the case of a man whose tongue was removed with a strong
wire ecraseur, which cut through the tissue of the tongue like a knife, much more quickly and cleanly
than had been intended. There was some smart hemorrhage at the time, and it was not easy to get
the man out of the operating theatre alive. The artery was not thoroughly secured, the bleeding
recurred and the patient rank and died a few hours later.

244 JACOBSON, TONGUE CANCER.

(2) The writer has seen again and again, however carefully the tight-
ening of the loop has been managed, that this is, finally, not fine enough
to divide the lingual artery, which is dragged out in the eye of the loop ;
it has, after all, to be secured by ligature or torsion, often not without
previous furious bleeding.

The galvanic ecraseur has not been described. I mention it here
only to condemn it. During the operation the loop may break, or it
may cut its way too rapidly through softened tissues, especially if the
heat used is too great. Later on, the patient has still to run the gauntlet
of the risks of septic lung-trouble and secondary hemorrhage, which
the use of this treacherous instrument entails.

After-treatment. — The chief objects here are: (1) To keep the
wound sweet. (2) To give sufficient food. Several English surgeons
have lately drawn attention to Kocher's method already alluded to, of
packing the wound with antiseptic gauze and bringing a drainage tube
out into the submaxillary region. Mr. Butlin gives with especial care
the details with which this method has been employed by Kocher him-
self, who lost only one patient from the operation in fourteen cases, and
by Billroth, whose results, published by Wolffler, show the last seven-
teen cases thus treated all to have been successful. I have not myself
made use of this method for these reasons: (1) I consider that other
means, especially that of Whitehead, give as good results and in a way
more agreeable to the patient, and I may add here that, out of twenty-
two cases of Whitehead's operation, I have lost only one from the
operation.1 (2) That this method of packing with gauze does not and
cannot give absolutely reliable aseptic results. It would, I think, be
easy to prove this from the constant soaking of saliva and other matters,
in which this wound differs from others ; but no better proof can be given
than the fact that a patient in whom Mr. Butlin himself made trial of
this method died, on the eighth day, of septic pneumonia.

The treatment I have made use of is as follows: For some day*
before the operation I make the patient practise* frequently washing out
hit month with Condy's fluid, sitting up, with the head alternately
dependent on either side, lie also gets used to feeding himself with a
drainage tube attached to a feeder spout, and passed by himself to the
back of liis throat.3 After the operation, the cut surface is brushed •
with a dilution of zinc chloride, gr. x-J ;* or of iodoform in ether; of the

1 The patient here wm a Jew, prematurely aged, with epithelioma supervening on syphilis, who
.li.-l of Im..i,. Iw pBinmOWlH M the. eighth day. I fear that this was septic, though my colleague, I>r.
Mahomed, who saw the patient during life and made the post-mortem examination, was of a different
OpteWw, Mag chiefly influenced l>y the ««e.t endition of the mouth.

* This gives him something to occupy hi-, mind and cleanses the mouth.

» If the patient Is at all intelligent, he will do this for himseir far more painlessly than an assistant
can.

' M stronger solution should be used, for fear of causing cellulitis In the submaxillary regions.

JACOBSON, TONGUE CANCER. 245

. I prefer the former at this time. Morphia is given as freely as is
safe, with ice t<> rook, and. if the patient's condition is low, milk and
brandy are administered, either by a soft oesophageal tube or by enemata ;
but 1 have generally found that, after the first BU hours, a patient, pre-
viously practised in the matter, will give himself sufficient food.1

r the patient has had his first sleep, the surface is brushed over
every two or three hours, at first with iodoform and ether, and the patient

on encouraged to sit up and wash out his mouth constantly with

ly "s fluid. He should be kept warm and free from draughts and
either propped up or turned on either side. I try to have my patients
sit up a little on the second day, if possible, and get them up, when this

asible, into an arm-chair, by the fifth or sixth day. Yolks of eggs,
arrowroot, soups, pulped vegetables in broths and the like are soon added
to the milk and brandy.

OF Failihk. — 1. Broncho-pneumonia, pneumonia, abscess
and gangrene of the lungs. These must be placed first on account of
their frequency. Septic in their nature and due to the patient's breathing
foul gases and drawing down putrid fluids into his lungs, their treatment
must be preventive, every endeavor being made to keep the mouth sweet
and to relieve the patient's breathing, by attention to the details already
gi%'eu.

'_'. Hemorrhage. This is rarely met with at the time of the operation

- .on after, it' every spirting artery has been properly secured. It

will also be rarely met with as a secondary complication, if the wound

ha> been kept sweet. In cases of bleeding, if the application of a silk

ligature to the bleeding point, taken up by a Spencer Well's forceps or

a tenaculum, is impossible, firm pressure with a sponge on a holder should

be made use of alter all clots have been removed. If the wound is foul,

it should be cleansed by brushing it over with iodoform and ether or

with turjH.ntineand should be lightly plugged with strips of gauze wrung

out of the latter, which is a most powerfully cleansing styptic* and one

always to be used in preference to perchloride of iron. If all the above

fail, either applying and leaving in situ& pair of Spencer Wells's forceps,

packed around with soft gauze, or ligature of the lingual as far back as

!e must be resorted to.3

llulitis; erysipelas. 4. Pysamia. 5. Exhaustion, more rarely

k.. 6. CEdenia of the glottic 7. Suffocation from falling back of
the tongue, tf. Recurrence. This last and most important cause of
failure I purpose to consider in another communication.

1 If tliis is nut Che case, a soft tube mast be passed.

* I baTe learned the value of t!ii» in sloughing wounds from Mr. Banks. Clinical Surgical Notes,

* If the bleeding is of the nature of oozing, one or two injections of ergotin should certainly be used.

246 BOSWORTH, ASTHMA,

ASTHMA,

WITH AN ANALYSIS OF EIGHTY CASES, WITH ESPECIAL REFERENCE TO
ITS RELATION TO LOCAL DISEASES OF THE UPPER AIR TRACT.

By F. H. Bosworth, M.D.,

PROFESSOR OF DISEASES OF THE THROAT IN THE BELLEWE HOSPITAL MEDICAL COLLEOF.,

SEW YORK.

In reviewing the literature of asthma, at the present day, when our
knowledge of this disease has become systematized and definite, one is
particularly struck with the exceedingly vague and indefinite views which
have prevailed in regard to it up to comparatively recent times, and
particularly with the curious theories which have been advanced to
account for the symptoms which characterize it ; for, while ancient
observers could not fail to have their attention prominently attracted to
it by the peculiar character of its manifestations, yet I find that it is
rather as a symptom than as a disease, that most writers deal with it.
Even as late as 1874, we find Bennett1 devoting only a few lines to its
consideration as a symptom of emphysema and bronchitis, rather than as
a distinct disease, while Watson, in his classical work on the Practice of
Physic, although devoting a chapter to the subject, makes the some-
what naive confession that he has never listened to a case by ausculta-
tion. As early, however, as 1852, we find careful observers searching
for some rational explanation of the peculiar symptoms which charac-
terize this curious affection. As far as we know, Bergson2 was the first
to make it a distinct disease, although its individuality was denied by
Rostan8 and by Beau/

The ancients believed the disease to be due to spasmodic contraction
of the bronchial tubes. This view was, however, controverted by
Laennec, who cites, as an argument, those cases of asthma in which we
have puerile breathing over the entire chest, thus showing that the
capacity of the lungs may be increased during a paroxysm rather than
diminished. Copeland calls the same cast's nervous asthma, while Walslie
suggests the term hainic asthma. Dr. Bree takes a different view, be-
lieving the disease due to some specific irritant in the air tubes and
that the asthmatic paroxysm is All effort tocxpel these so-called irritating
humors.

Beau,1 whose treatise has already been referred to, believes that all
cases develop t'rom a primary bronchitis,

Todd* regards the disease as humoral, comparing it to gout or rheuma-

1 I'rin.lplet and Practice of Medicine. American edition. Philadelphia, 1874.

* Heche rr he* mr l'aathme, 1852.

* Do I' a»t lime ; Qal. dee hopitaux, No. 31, 1856.

* Train- i Unique et pratique de I'aueculUtton. Parli, 1850.

» Arch. Geiierale, toL 78, p. 156. « Medical Gazette 1

BOSWORTH, ASTHMA. 247

i ism, and believes the materies morbl affects the respiratory centre;
while Budd1 divides it into two forms; one depending upon cardiac
disease, emphysema, etc., the second form due to a spasm of the respira-
tory muscles. The mere fact that an attack of asthma is always pre-
ceded by a feeling of a want of air and increased respiratory effort is
enough to controvert this view. That this view has been held, though,
for some time, is shown by the fact that so recent an author as Wintrich1
advances essentially the same idea.

The first to write a really exhaustive work on asthma was Henry
Eyde Salter.' His work has become a standard one, and his views have
been adopted by most subsequent writers on general medicine. He
makes the following propositions:

. Asthma is essentially, perhaps with the exception of a single
class of cases, a nervous disease, the nerve centres being the seat of the
essential pathological 'condition. Second. The phenomena of asthma,
distressing sensation and demand for extraordinary respiratory efforts,
immediately depend upon spasmodic contraction of the cells of unstriped
muscular fibre in the bronchial tubes. Third. The phenomena are
excito-motor or reflex actions. Fourth. The extent to which the
nervous system is involved differs much in different cases, being, in some,
restricted to the nervous apparatus of the air-passages themselves.
Fifth. In a large number of cases, the pneumogastric, both gastric and
pulmonary portions, is the seat of the disease. Sixth. In a large class
of cases the nervous circuit involves other nerves beside the pneumo-
gastric. Seventh. There is still another class of cases in which the irri-
tation is central. Eighth. In a certain proportion of cases the irritation
is humoral.

We find here that the bronchial spasm-theory of the ancients was
fully adopted as the result of large clinical observation and study, and
maintained by Salter in the several editions of his popular work. This
theory is the one adopted by Biermer.4

We see, then, that, according to Salter, asthma is essentially a neurotic
disease, and this theory, with some modifications, is the one adopted at
the present day. Dr. Burney Yeo* attempts to draw an analogy between
the extreme distention of the lungs in asthma and abdominal distention
in hysteria. This observation is curious perhaps, but scarcely harmon-
izes with clinical observation. Morton6 draws a similar analogy between
asthma and spasmodic croup. The sudden nightly attacks, with daily
remissions; a certain periodicity observed in the attacks of both dis-

1 Med. Chir. Transactions, vol. 23. London, 1840.

low's Haii'lLuch der Path, und Ther., Bd. v. Ab. 1.
*On Asthma ; Its Pathology und Treatment. London, 1860.
4 Ueber bronchial Asthma, Sammluiiji klinische Vortrage, 1876.
* London Practitioner, 1881.
I liritish Medical Journal, January 22, 1877.

248 BOSWOETH, ASTHMA.

eases ; a dry first stage and moist second stage ; all seem to him to point
to a certain similarity between the two diseases. Another curious ob-
servation which he makes is that the tendency to asthma begins at
about the time when the tendency to spasmodic croup ceases. He be-
lieves that both croup and asthma are due to disorders of innervation
of the larynx, on the one hand, and of the bronchial tubes, on the other,
the immediate cause of the paroxysm being excess of venous blood in the
medulla. This observation is also incorrect by the decided error in both
premises.

In the diligent research after the hidden causes of disease so charac-
teristic of the present day, Leyden1 claims to have discovered certain
elements in the sputa of asthmatics, known as " Ley den's crystals," and
misnamed, for some reason, Charcot's crystals.

Ungar, of Bonn, in an investigation of thirty-nine cases of spasmodic
asthma, as recently as 1882, found these crystals in the sputa, but also
found that they increased in number the longer the sputa stood, thus,
to a certain extent, vitiating Leyden 's theory.

Quite recently, Dr. Pfuhl2 relates the case of a soldier whose sputa
contained large numbers of the crystals of Leyden, without any evidence
of asthma. Further, he has examined the sputa in 855 cases of pul-
monary disease, and has only found the crystals in the one case mentioned
above. An attack of asthma, as we know, consists in the occurrence
of more or less well marked symptoms of oppression of breathing,
with a certain amount of periodicity, coming on suddenly, generally
at night, and lasting for several hours, the dyspnoea obtaining both
during inspiration and expiration, while the cessation of the attack is
accompanied by a more or less profuse serous and sero-mucous expectora-
tion. This series of phenomena has been explained by the writers
quoted above on the theory that this dyspnoea La due to the contraction
of certain muscular fibres, which anatomists have demonstrated as BX«
isting in t lie bronchial tubes, down to their smallest ramifications. It is
difficult to understand why the early writers did not vigorously question
this conclusion as failing to explain rationally the phenomena of a
paroxysm of asthma. The only explanation of this is that their
knowledge of pathological processes was unequal to supplying a more
plausible theory.

In 1872, however, we find the spasm-theory called in question, and

what, to my mind, is a far more plausible one advanced by Weber,*
who was the first to teach us that tin- cause of the paroxysm lay in a

- of the vasomotor nerves presiding over the vessels of the bronchial
mucous membrane. Under the influence of this vasomotor paralysis,

PW*I A.-. I.., HI .M. 1ST l . * Deutsche med. Zeitung, 1S87, No. 70.

* Tageblatt dor 4oto Naturveraummlung iu Lelptig, page 159, 1 1

BOSWORTH, ASTHMA. 249

there occurs, from some cause, a sudden letting up of the control which
is exercised over the calibre of the bloodvessels, whereby they become
distended to such an extent as markedly to interfere with the passage of
air through the bronchial tubes. This paralytic condition having
lasted several hours, the membrane maintaining a dry condition, as is
always the case in the first stage of the inflammatory processes, there fol-
lows an escape of serum and sero-mucus, thus relieving the engorged
bloodvessels, which soon regain their normal calibre, coincident with the
cessation of the paroxysm. We thus have a thoroughly rational and
plausible theory in explanation of the symptoms of spasmodic asthma.
As to the causes, however, of the disease, little has been said further than
the causes already stated, as laid down by Salter. Weber's paper, how-
ever, was followed by a series of clinical observations which largely lent
weight to his theory and also threw much light on the causes of the dis-
ease. The first observation of note in this connection was that of Vol-
tolini,1 who reported a case of asthma, due to the existence of nasal
polypi, as shown by the fact that the asthma promptly disappeared on the
removal of the nasal growths. This observation was followed by a large
number of similar reports by Hanisch, Porter, Daly, Todd, Spencer
and others, as noted by Mackenzie,2 and gave rise to voluminous dis-
cussions by Shafer, Friinkel Bresgen, Hack and others, not only on
asthma as a reflex disease due to nasal polypi, but also as due to other
nasal disorders.

As before stated, the literature of this subject has assumed large and
voluminous proportions, but it still inclines itself to the subject of
asthma as a reflex disease. Now, I do not propose to enter into this sub-
ject of reflexes, which has always seemed to me as a term oftentimes
used as a cloak to conceal our ignorance of the direct relation between
cause and effect, but I am convinced that, in very many instances
of morbid symptoms occurring as a result of reflex disturbance, we
can offer a more rational explanation than " reflex," in the sense in
which the term reflex is so often used at the present day. Following
Voltolini's observations that nasal polypus was the cause of asthma, and
intimately connected with the same line of investigation, came the study
of hay-fever. The first impetus, as I think, to this line of investigation,
was a paper by Daly.5

Dp to this date, hay-fever had been regarded as simply a periodical
coryza or influenza, in which the paroxysms were characterized by the
same symptoms as are met with in an ordinary cold in the head. As a
matter of fact, however, acute rhinitis and an attack of hay-fever differ
in a marked way, in many respects. This fact was soon recognized, and

1 Die Anwendung d. Galvanokaustik Wien, 1872, p. 24fi, 4th ed.

1 Di«nmeof the Throat and Num. American edition, toI. ii. Philadelphia, 1881, p. 357.

* Archives of Laryngology, rol. iii. p. 157.

VOL. 96, WO. 3. — SEPTEMBER, 1888. 17

250 BOSWORTH, ASTHMA.

a new name was given to hay-fever, vasomotor rhinitis. We have, thus,
suggested a connection between the two diseases, and, as a clinical
fact, the two diseases are intimately connected ; for, as we know, a large
number of hay-fever patients suffer from asthma, following soon after
the onset of their nasal symptoms. A natural division of cases of
asthma into hay-asthma and perennial asthma is thus made, the one term
being applied to those cases that are attended with hay-fever, the other
to those cases in which asthma occurs without reference to seasons ami
without the preceding influenza. The question now arises, What, if any,
connection exists between the two, or how far are these two diseases one
and the same ; and, again, what is the connection between hay-fever and
asthma, and are they not, in many respects, the same disease ? In a
paper read before the American Climatological Association, May 28,1
1885, I first advanced the view that hay-fever and perennial asthma
are virtually one and the same disease, the one being a vasomotor
rhinitis, the other being a vasomotor bronchitis, the paroxysms being
excited, in each case, by some peculiar atmospheric condition. The
atmospheric condition, as we know in hay-fever, is the presence of the
pollen of flowering plants or some other vegetable emanation ; whereas
the atmospheric condition in perennial asthma, as we may designate
those cases of asthma which occur during the whole year and do not
depend upon hay-fever, is dependent upon some obscure element which
we are, as yet, unable to trace with the same degree of definiteness as
we are enabled to trace it in hay-fever. Hay-fever is dependent upon
three conditions :

First. A neurotic habit, as was conclusively shown by Beard.2

Second. The presence of pollen in the atmosphere, as shown by the
unrivalled experiment of Blackley.*

Third. X disordered condition of the nasal passages, as shown 1»\
Daly.4

Now, the view that I advocated is that asthma also is dependent mi
three conditions :

Firtt A general neurotic condition, as demonstrated by Salter.'

<</. A diseased condition of the nasal mucous membrane i. not toe
bronchial).

Third. Some obscure condition of the atmosphere exciting the
paroxysms.

The view as regards the neurotic condition is generally accepted;
that as regards the atmospheric oondition, I think, is one which
must be generally accepted by all observers when we consider the
diurnal and seasonable periodicity of the paroxysms. As regain's the

> New Turk Medical Journal. April 24, May I, 1886.

* Ilav-f.-M-r .>rSmiimrr-<HtHrrli. New York, IC7A.

' Ha.i-lenr. Lm4m, 1873. « Loc. cit. 0B.«tt

BOSWORTH, ASTHMA. 251

Data] condition as a predisposing cause of the attacks, the view is a
novel one, and, naturally, would be looked upon as the hobby of a
ialist. In my original paper, I made this assertion, that " a large
majority, if not all, cases of asthma were dependent upon some obstruc-
tive lesion in the nasal cavity. This is evidenced by the immediate
relief from the exacerbation by the use of cocaine in the nose in every
case in which I have tried it, and, furthermore, by the cure of so many
cases by the removal of the obstructive lesion in the upper air-passages."
This paper was read two years ago. The views there stated I would
repeat with even more emphasis, for subsequent clinical observation has
only served to confirm me in my belief of their correctness. That the
lesion in a paroxysm of asthma is a vasomotor paresis of the blood-
vessels supplying the bronchial mucous membrane, and not a bronchial
spasm, I do not discuss, but accepting this theory as the only one which
can explain the symptoms, the question arises, What is the connection
between the nasal mucous membrane and that of the bronchial tubes ?
I have already written1 fully on the subject of the great respiratory func-
tions of the nasal mucous membrane, and I need not repeat them here
at length. In brief, the most intricate, the most delicate and most im-
portant part of the whole respiratory tract lies in the nose, in that mass
of bloodvessels which we call the turbinated tissues, and which serve to
supply the inspired air with moisture, by pouring out upon the surface
of the mucous membrane a large amount of water — sixteen ounces in
the course of the day — by which the inspired air becomes saturated
with moisture, this function being necessarily regulated with an extreme
degree of nicety of adjustment. This establishes, in what way or through
what nerves or ganglia I do not discuss, but to my mind does unques-
tionably establish a most intimate connection between the two portions
of the respiratory tract. The blood supply in the nose being regulated
by the same vasomotor tract as that which regulates the blood supply of
the bronchial tubes, a disturbance in one region is liable to be followed by
a disturbance of the other; a morbid condition in one region renders the
other especially susceptible to diseased processes. This, briefly, is the
history of the connection between the two parts. Hence, we see, there-
fore, how a diseased condition in the nasal cavity may predispose a
neurotic patient, under favorable atmospheric conditions, to an attack
of asthma; the same line of reasoning, as will be noted, being followed
here as in the case of hay-fever. This connection between the two
regions I have not found alluded to by any writers, and yet I cannot
but think that Hyde Salter2 must have entertained a somewhat similar
idea when he says, in speaking of the causation of asthma, that we may
divide the cases into two classes : First, cases in which the essential cause

1 Loc. cit. *Op. cit , pagiSl.

252 BOSWORTH, ASTHMA.

of disease, " that which constitutes the individual an asthmatic," is some
organic lesion, possibly not appreciable, either in the bronchial tubes or
some part physiologically connected with the bronchial tubes. Second,
cases in which the organic lesion does not exist, in which the tendency to
asthma is due to something from within, not from without, in which the
cause of disease is a congenital and possibly inherited idiosyncrasy.
The large clinical observation and study which were the basis of Salter's
classical work, could not fail to have impressed upon him that a diseased
condition of the upper air-passages was prominently active among the
predisposing causes of asthma. It would seem a rather broad statement to
make that all cases of asthma find their predisposing cause in intranasal
disease, and yet I am very confident that it is very largely, if not
entirely, true. Certainly, in my own observation, I have seen no case
in which this could not be stated. The question suggested by Macken-
zie1 here arises, What constitutes a typically healthy nose? Mackenzie
seems to think that there is a very large difference in individuals, even
in health, and rather suggests that a typically healthy nasal cavity is
difficult to find. On the contrary, I think that every nasal cavity
which shows a departure from the normal type should be regarded as
in a diseased condition. The true test, however, in these cases is this :
if we find diseased conditions, the removal of which cures an asthma, my
proposition, in that individual case, is certainly established. I make
the general statement that all cases of asthma have intranasal disease,
without giving definite proportions. This may seem rather broad, when
we find eminent physicians of the present day, such as Fothergill,
Flint, Loomis and others, adhering to theold theory of bronchial spasm,
and not mentioning pathological conditions in the nasal chamber as a
possible cause of the disease. That my view is by no means entertained
by laryngologists is shown by the fact that Bocker* makes the statement
that asthma is seldom associated with polypi and seldom cured by their
removal, and that hay-asthma is caused by direct irritation of the
bronohi, and, further, that, normally, asthma cannot be produced in
the nose.

This first assertion of Bocker seems, to me, to be a very grave reflec-
ti'Mi on his skill as an operator. In the Union for Internal Mediums,
May and July, 1886, Lublinski, Heyman, Bocker and Krause assert
that, in many cases, asthma is independent of a pathological condition of
the nasal passages. Scheoh,1 however, states that, in sixty-four per cent.
of cases of asthma, he (band intranasal disease, and further adds that
there must be associated excessive nervous irritability —in other words.
tin- neurotic habit,

' liny (V\.r, LsodaB, IMS, \vig* 25.

Ittohl mi-ilh-in...,'li,- W.i. h.'in.lirift, lssfi, N<*. 26 and 27.
s aiUuclu'iicr niodlclnlnclie Wochcnichrift, 1887, Nob. 40 mid 11.

BOSWORTH, ASTHMA. 253

In looking over my notes, I find I have recorded histories of eighty-
cases of asthmatics treated during the last five years. Not satisfied
with the study of these records, and in order to make my investigation
as thorough as possible, and, at the same time, bring the reports up to
date, I mailed to each one of these patients, some of whom I had not
seen for a considerable time, a printed circular, in which I propounded a
series of questions. These questions I will not recapitulate, as they are
suggested by the headings in the following analysis of my tables. The
last question was, " Please state candidly and without favor what benefit,
if any, you have received from the treatment, and to what you attribute
your improvement or cure." The following analysis sets forth the
result :

Total number of cases of asthma 80

Males 47

Females 33

I lav asthma 34

Males 26

Females 8

Perennial asthma 46

Males 21

Females 25

Perennial Asthma — Family History.

Clear in 9

Neurotic 3

Bronchitis and asthma 2

Asthma ........... 4

Asthma and hay fever 4

Bronchitis 2

Asthma, bronchitis and neurosis 1

Phthisis 1

Hay fever 1

Asthma and neurosis 1

Unknown 18

Total 46

Hay Asthma — Family History.

Asthma in 14

Clear in 5

Phthisis and neurosis 1

Neurotic 2

Hay fever 2

Asthma and neurosis ........ 2

" * hay fever 2

" " neurosis and hay fever 1

Neurosis and hay fever 1

Unknown 4

Total 34

The prominent feature shown here is the large preponderance of cases
which show a decided neurotic family history ; 25 of the 30 cases of

254

BOSWORTH, ASTHMA.

hay-asthma being of inherited neurotic habit, when the history is known,
while in the perennial form 16 of the 28 cases, in which the history is
ascertained, show the neurotic tendency.

Age of first attack.

1st ten years of life

2d "

3d "

4th " " "

5th "

Over fifty years of age

From birth

Total .
Average age of first attack
Oldest case, 72 ; youngest, congenital.

Perennial asthma. Hay asthma.

...

29 years.

24 years

We notice that the tables show that the largest number of cases of
asthma, in both forms, develop during the third decade of life, while no
period is notably exempt. This diners from Salter, who states that most
cases develop during the first decade.

Climatic Influence on Hay Asthma.

Greatest relief at high altitude

U H lf)W

'• " sea

" " New York City
Suffer equally everywhere .
Unknown ....

Total .

Climatic, Influence on Perennial Asthni'i.

Greatest relief at high altitude
Suffering more "

Greatest relief at sea "
Suffering more "

" equally everywhere
Greatest relief at low altitude

" in New York City
Unknown

Total .

Combining these two tables in one we find as follow- :
Clinvxtic Influences on the Two Forms of Asthma.

11
1
6
3
3

11
1

•j

7
13

Better at high altitudes ....
" at sea shore ....

. n

" in city

Unaffected l>y locality

liar

Effect of locality unknown ....

. 9
. 18
. 9
. 19

Total

BOSWORTH, ASTHMA. 255

We notice here that whereas in hay lever the seashore affords the

relief, after asthmatic symptom* set in the same rule applies to

both forma, and that high altitudes are most beneficial ; and yet I think

DO rule can be formulated for the cases as a class. They are essentially

tickle, and each one must be advised from personal and individual

ierations.

11 1 1 Asthma.

Nasal symptoms immediately preceding attack, such as

•/iiii: with watery discharge from the nose . . .29
No symptoms preceding attack ...... fi

Total J4

. Perennial Asthma.

.! symptoms preceding attack 33

N> nasal symptoms preceding attack 12

Cutaneous eruption preceding attack 1

Total 46

This showing, it seems to me, is of the greatest importance, as sus-
taining the original assertion made in the early portion of the paper.

It should be mentioned that many patients entirely ignore the nasal
symptoms, in the larger discomfort arising from the dyspnoeic attack, and
only recall them when their attention is turned in that direction. We
see, then, that, of the 80 cases, the asthmatic attack set in with sneezing,
etc., in 62.

The one case in which a cutaneous eruption occurred is interesting
only with reference to the neurotic explosion.

Hay Asthma.

History of previous catarrhal trouble 23

X.j hist' >ry of previous catarrhal trouble . . .11

Total

Perennial Asthma.

History of previous catarrhal trouble .
No history of previous catarrhal trouble

SI
15

Total 46

We see here that, of the 80 cases, 54 give a history of previous
catarrhal trouble. Yet the testimony of patients in this matter is not to
be relied upon, as many patients have undoubtedly notable impairment
of the nasal respiratory function, without being conscious of suffering
from what they call catarrh. Moreover, in a large proportion of nasal
:ders, the symptoms are referred, by the individual, to the throat,
while " catarrh " is popularly referred to the nose.

256 BOSWORTH, ASTHMA.

Intranasal Condition — Hay Asthma.

Hypertrophic rhinitis 9

" " and deflected septum . . .12

Polypi and deflected septum 5

Polypi •• 4

Deflected septum 3

Elongated uvula 1

Total 34

Intranasal Condition — Perennial Asthma.

Hypertrophic rhinitis

Nasal polypi

Hypertrophic rhinitis and deflected septum
Polypi and deflected septum

Deflected septum

Adenoid and hypertrophic rhinitis

Total 46

I have never known a case of hay-fever or asthma to occur in other
than an obstructive lesion of the nose or upper air-passages, as will be
seen by this table ; this was the case in every one of the 80 cases, in-
cluding the elongated uvula, which became a source of respiratory

obstruction.

Treatment — Hay Asthma.

Hypertrophic rhinitis, treatment by caustics: Cured, 7; improved, 6; un-
improved, 1.

Deflected septum, operated on by author's nasal saw: Cured, 8; improved, 6.

Nasal polypi treated by snare, without caustics: Cured, 2; improved. 1.

Treatment by snare and septal saw in cases of polypi and deflected septum :
Cured, 1 ; improved, 1.

Cases treated by uvulotomy: Cured, 1.

Treatment — Perennial Asthma.

Hypertrophic rhinitis, treated by caustics: Cured, 8; improved, 5.
Polypi treated by snare, without caustics : Cured, 15 ; improved, 3.
Deflection of septum operated on by author's nasal saw : Cured, 3 ; im-
proved, 4; unimproved, 1.
Adenoid growths removed by snare : Cured, 2.

The treatment, as will be seen, has been such as our English friends
regard as harsh, and in many cases unwarranted. I think it but justice
to say that, in some cases, patients have been unwilling to continue on
account of this, and yet, with the use of local anaesthesia, these opera*
tions are not painful ; it is the nervous strain on this class of patients
which has taxed them most severely. That the surgical treatment of
nasal diseases is fully justified I think the following table amply
demonstrates :

Sfl of Trcntmrnt — Jfay As/lnmi.

Cured 18

Improved 14

UnimproTed .......... 1

Unknown 1

Total 84

HANDFORD, PERFORATING ULCERS OF FEET. 257

Result* >>f Trxiti/i' ><t— /'>,■- a it i'il Asthma.

Cured 28

Improved 12

Unini|>rove«l .......... 2

Unknown 4

Total 46

It is not the province of this article to discuss the general therapeutics
of asthma, for, in the large majority of these cases, the treatment has
been purely local, and yet, in many instances, internal medication has
successfully been resorted to, such as the use of the iodides, zinc and bel-
ladonna, the three remedies on which I have placed the greatest reliance.

The poiut to which I desire to give the greatest emphasis is that local
treatment of the intranasal disease, which I have invariably found in
these cases, affords us by far the most satisfactory method of controlling
this distressing and heretofore intractable disease. This seems to be
particularly true when the case presents itself for treatment before the
age of twenty. In the above tables, four cases of hay-asthma and seven
of perennial asthma were under twenty, and all were cured.

It should be remembered that these cases have all come under the
observation of a throat specialist, and, hence, a very good reason is im-
mediately apparent why he should not see cases of asthma not de-
pendent on nasal disease. This I have endeavored not to disregard in
what has been written, and yet, if the foregoing statements may seem
extreme, I can only say that I have endeavored to analyze my cases
and report the results with fairness and candor.

PERFORATING ULCERS OF THE FEET, OF AT LEAST TEN

YEARS' DURATION, PRECEDING OTHER SYMPTOMS

OF TABES DORSALIS :

ASSOCIATED WITH CHARCOT'S JOINT LESION, AND (?) WITH PERFORATING
ULCER OF THE TONGUE.

By H. Handford, M.D., M.R.C.P.,

PHYSICIAN TO THE NOTTINGHAM GENERAL HOSPITAL.

The following case is interesting on many grounds. It commenced
as a typical example of perforating ulcer of the foot ; and afterward
became symmetrical, affecting the soft parts over the metatarso-phalan-
geal articulations of both great toes. Sensation was not sufficiently
interfered with to prevent pain on walking being his chief complaint.
It was the pain that made him beg to have the toe amputated. The

258 HANDFORD, PERFORATING ULCERS OF FEET.

ulcers frequently healed after prolonged rest, showing that mechanical
injury, in addition to altered innervation, was necessary for the continu-
ance of ulceration. The toes were eventually amputated close to the
site of ulceration, and yet the healing of the wounds was fairly rapid
and sound. Though now associated with several symptoms of tabes
dorsalis, the perforating ulcers existed for six or eight years, at 1<
without any discoverable sign of locomotor ataxia, and even now the
ataxic symptoms proper are very slight indeed.

If we accept the positive assurance of the patient that the ulcer of the
tongue was not preceded by any stage of induration, we must receive it
as an example of a very rare condition: namely, perforating ulcer of
the tongue ; and, moreover, a perforating ulcer which has healed.

On the whole, it appears to be a case of tabes dorsalis in which the
peripheral multiple neuritis, which is almost invariably found at some
stage, has appeared early, as shown by the ptosis, optic atrophy, joint
lesion (knee) and perforating ulcers. It is doubtful whether it may not
be an instance of true tabes dorsalis commencing in a peripheral neuritis,
as suggested recently by Professor Leyden, and affecting the posterior
columns of the cord secondarily. In this suggestion I have assumed
peripheral neuritis to be the most probable cause of the joint lesion as
well as of the perforating ulcers. In this connection the " Report of the
Committee on Joint Disease in Connection with Locomotor Ataxia,"
published in vol. XX. of the Transactions of the Clinical Society of London,
is interesting, and especially the case of J. Griffiths related on page 299.

Case. — "W. W., aged forty-one, a bricklayer's laborer, and formerly
a laborer at the Gas Works, was admitted into the Nottingham General
Hospital, under my care, on March 10, 1887, complaining of swelling
of the left knee.

He had gonorrhoea and a sore on the penis twenty years ago, but does
not remember having any rash or sore throat. We may take it then,
that, if he had syphilis, the secondary symptom* were mild. He has had
no tertiary affection, unless the condition of the tongue to he presently
described was such. About fifteen year< ago, a railway metal crushed
hit right graft! toe, and burst the skin. The wound soon healed, and

remained sound lor four or five years. After that, a Bore appeared on
the plantar surface of the right great toe opposite the metatarto-phaiaa-
Lrfal articulation, [a a fesr months, a similar sore appeared in exactly
the same position on the left great toe. With rest these sores readily

healed, hut as readily broke OUt again RS soon as he began to walk and
work. I t'n-t saw him in L879, when he was in the hospital under the
care of my colleague, Mr. Wright. The ulcers were rounded and dl
and a sinus led down to the sesamoid hones which necrosed and eventu-
ally were exfoliated. The ulcers were surrounded by a /one of very
Stly indurated and thickened epithelium. The patient was anxious
to have his toes amputated, hut eventually the ulcers healed. a- they
had done before. At this time there were no symptoms of talus.
After many vicissitudes, he determined to have the left toe ..If. It was

HAXDFORD, PERFORATING ULCERS OF FEET. 259

amputated about four years age, and the wound healed well. For some
months after that he was able to work as a bricklayer's laborer, and go
up a ladder with a load of bricks. There was evidently no ataxia at
this period. Two years later the right great toe was similarly removed
at his argent request, by my colleague, Mr. A. < '. Taylor, on account of
the pain of the ulcer on its under surface. I have no record as to the
or not of any area of anaesthesia, or even of diminished sensi-
bility, but there is no doubt that on both feet the ulcers were painful
during walking, and it was because of this pain that he insisted on
having the toes removed. It is curious that a neuritis sufficient to
affect gravely the nutrition of the part should not have interfered more
with sensation. Since he lost both toes he has not been able to work.

Fio. 1.

Charcot'* joint lesion affecting the right knee-joint. (From a photograph.)
The lose of both great toes U shown.

Eight or nine weeks before his admission into the hospital on the
present occasion, his right leg became swollen from the knee to the
ankle, and later the swelling extended up the thigh. It was not due to
any injury. N far as he is aware. There was much pain in the knee at
first. Now the swelling of the leg ami thigh is gone, as is also the pain;
but the knee remains much enlarged (Fig. 1). There is no distinct
fluctuation, but much pulpy swelling, and considerable enlargement of
the ends of the bones. The internal lateral ligaments have yielded, and
there is considerable genu valgum on standing, which he can do without
pain. The movements of flexion and extension are free, and he can
walk with the aid of a stick.

There is a large depression about the middle of the left border of the
tongue. It is quite soft, smooth and soundly healed. He thinks he

260 HANDFORD, PERFORATING ULCERS OF FEET.

bit his tongue about a year ago, and that an ulcer followed. He is sure
it was not preceded by a hard lump. It is doubtful whether this has
been a gumma or a perforating ulcer. The history and the absence of
induration and puckering suggest the latter.

He has some cardiac irregularity on excitement, but no murmur.
He sleeps moderately well, his speech is very thick, and he complains of
occasional shooting pains. His sight is fairly good. He has a very
morose expression, with thick, heavy lips and moderate double ptosis
(Fig. 2). There is commencing double optic atrophy. His hearing is

From a photograph ; showing the double ptosis, thick lips and general morose expression.

good, but taste is somewhat defective, though he can distinguish salt and
sugar. No affection of the muscular sense could be detected. There is
complete absence of knee-jerk on the left, but on the right the knee is
too much swollen for any definite result to be obtained. He cannot
stand with the eyes closed. He frequently has some difficulty in passing
water, and occasionally passes it involuntarily. Common sensation
appears to be blunted, but nowhere lost. With the eyes blindfolded he
could generally tell when he was touched on the leg with a feather, and
usually distinguished the proper side, i. e. , right or left; but he was
very frequently wrong in localizing. Occasionally, after he had been
touched many times, he quite ceased to be able to tell correctly the spot
touched; ana even continued to feel touches and localize them for a
minute or two after the experiments had ceased. He could localize
correctly a touch with the finger at first, and distinguish it from ■ knife-
point, but afterward he confused the two. There was no very evident
delay in the perception of sensations. The sense of contact is less acute
on the stump of the right toe than on that of the left. Heat and cold
cmii only be distinguished in the legs when the water in the test-tube is
boiling.

He can place the legs in any position indicated, and also tell in what
position they have been placed for him. In the upper extremities

HAXDFORD PERFORATING ULCERS OF FEET.

261

common sensation is acute as compared with the lower. Sensation to
pain is moderately good except on the left forefinger, where a pin stuck
into the skin, so as to stand up, was said to be a touch with a finger.

He remained in the hospital several mouths, but the knee did not
improve much and he went out. After he had begun to go about again
with the aid of a stick, a fresh typical perforating ulcer, surrounded by
a zone of thickened epithelium, developed on the under surface of the
stump of the left great toe (Fig. 3). In a month or two, however, it
\\;i~ healed.

Fig. 3.

Perforating ulcer on the stump of the left great toe which had been amputated four years
previously for a perforating ulcer higher up.

A year later, in March, 1888, he remained in very much the same
condition. The ulcer remains healed, but he has had a fresh one on the
upper surface of the stump of the left great toe. This was evidently
eaoted by the friction of his slipper and eventually healed. He only
walks about the house with a stick. The knee remains unaltered, except
that it gives way more on walking, but it continues painless. The
tongue has not broken out afresh. He walks without any incoordina-
tion of movement ; there is no jerking of the limbs or stamping of the
heels.

262 HARRIS, EXTRAUTERINE PREGNANCY.

EXTRAUTERINE PREGNANCY TREATED BY CYSTECTOMY.
OR CYSTOTOMY WITHOUT EXSECTION,

WITH SPECIAL REFERENCE TO CASES IN WHICH THE FCETUS IS LIVING

AND VIABLE.

By Robert P. Harris, A.M., M.D.,

OF PHILADELPHIA.

Recent important changes in the treatment of extrauterine preg-
nancy, at all periods of development, and the diminished mortality under
exsection in cases in which the object is to save two lives, have led me
to take a more hopeful view of the whole subject than I felt warranted
in taking a year ago, in a paper entitled " Primary Laparotomy in Cases
of Extrauterine Pregnancy." The term primary has been so differ-
ently applied of late years, that it has ceased to convey to the mind any
definite meaning, such as it had until quite recently. Laparotomy has
become of such general use in many countries as a legitimate term, that
I can see no valid objection to its continuance ; but the nomenclature
has become deranged by the introduction of exsective operations at
every stage of embryonic and foetal growth, from three weeks to full
maturity. Thus we have exsection : 1, before rupture, while the embryo
is presumed to be alive ; 2, before the same accident, when the foetus is
already dead ; 3, after rupture, when the object is to save the woman
from bleeding to death ; 4, at a later period, when the foetus is alive,
and is being developed either subperitoneally, or within the abdominal
cavity; 5, at or near foetal maturity, in the hope of saving both child
and mother ; and 6, when the foetus has been some time dead, to save
the woman from the fatal effects of septic infection, hectic, peritonitis,
perforation of hollow viscera, etc. These various operations bear an
age in the reverse order of their enumeration.

The oldest exsective operation was simply the enlargement of a fatal
fistula of the abdominal wall, and the removal of a dead and putrid
foetus in fragments or entire. The next step in progress was to disregard
the fistula and make an incision into the cyst directly over some pre-
senting part of the foetus. This mi first done, on August 20, 159"), by
Jacob Noierus,1 in the case of Giralda Tiaca, of Grandiniano, upon
whom he had, on a former occasion, performed the first- mentioned
section, she having had two ectopic impregnations within a few years.

At a much later period, when surgeons became more venturesome,
the dead foetus was delivered by abdominal section while still unchanged
by putrefaction, there being no fistula: and, finally, a decidedly more

' Jacobus Prlmerotll " De Muli. rum M.nMt," 1655, p. 318.

HARRIS, EXTRAUTERINE PREGNANCY. 263

daring itep was taken, in the exsection of a living and mature foetus, in
the year 1813. Thia latter operation became designated in time, by way
of distinction, as the primary operation, and the older form, in which the
fu'tus ia already dead, as the secondary one. When Mr. Tait began to
allopian foetal cysts after their rupture, he claimed that his opera-
tion was better entitled to the term primary ; and now we have another
claimant in Dr. John 8. Ilawley. 0(f New York,1 who, with several others,
lias exsected a foetal cyst prior to rupture, and calls his a primary
laparotomy. We have also the same title given by Dr. Francis H.
ChainpiHvs.-' of London, to abdominal section in the latter half of preg-
Hanrij, flu- child being alive. So, as the term has in a measure lost its
original signification and now belongs to nothing definite, I must drop
it for the present, until the nomenclature is settled. In importance, the
operation designed to save mother and child is certainly primary, and it
was this which gave the distinctive title originally ; the primitive operation
is that described by Dr. Hawley as the first in the order of time.

The tabular record to date shows that the prognostic status of the
operation has been decidedly improved of late years; as is evinced by
the fact that four women have been saved under the last ten opera-
tions. By correspondence, either directly or indirectly with twenty of
the operators, I am enabled to fill up many points in the tabular matter
that would otherwise have appeared in blank, as well as to give an esti-
mate of the conditions of the women when subjected to the use of the
knife, and to state the causes of their death and of that of the children
who survived beyond a few hours or days.

When an extracted ectopic child is well formed, and has lived beyond
the first month, there is no reason why it should not have the same
I>n>spect of continuing to live that a normally delivered foetus has, but
for the fact that it is too frequently motherless, and is often much
neglected or injudiciously cared for. A fair proportion of ectopic
foetuses will be found perfect in form, and about one in three extracted
at full term will present all the signs of physical vigor. Of the thirty
children in my table, two boys, aged respectively six and eight years,
are now alive and well; a third boy had an intemperate father, and,
although hale and strong, was fed into cholera infantum at eighteen
months ; a fourth child, a female, whose mother survived, died of croup
at eleven months; a fifth fell a victim to diarrhoea at seven months; a
sixth was alive and well when lost sight of at six months; and a seventh
died of broncho-pneumonia at the same age.

The placenta always has been, and is still a subject for anxiety in the
exsection of a living or dead foetus. What to do with it was for years

1 New Tork Medical Journal, June Id, 1888, p. 648.

'- Transactions Obstetric.il Society of London f«r 1887, p. <56.

Abdominal Exsection of the Li vim

Date.

Operator.

Locality.

— -

Aug. 29,
1813

Dec. 7,
1814

Dr Brukert

Dr. Domenico Novara

1827 ? Dr. Matfeld

Mar. I, 'Dr. Hauff
1841
1852 Prof. I'ietro Lazzati

Mar. 27, Prof.EugenKceberle
1863

April 21, Dr Bob. Greenhalgh
1864

Mar. 3,
1870

Oct. 5,
1872

Aug. 14,
1875

Mar. 5,

1877

May 25,
I 1877
18 Hot. B,

I 1877
14 Aug. 19,
1878

May 29,
1879

Dae. r.t,

1879

l!i

'21

'-".'

Dr. E. Paul Sale

Dr. John Scott
Mr. T. B. Jessop

Prof. Otto Spiegelberg

Dr. Heywood Smith
Dr Henry Gervis
Dr. Ernst Frankel

Prof. Carl Schroder

Dr. B. Chris. Vedeler

Jan. 10,
1880

Jan. 31,
1880

Mav 11,
1880

.lulv 86,

.In I v '.»,
1881

July 18,
1881

•2:1 K.-i, 18,
I 1882

18M

2.'. .Inn.. 8,

1880

Prof C. C. Th. Litz-
inann

Mr. Lawson Tait

Dr. H P. C WiUoL

Dr. W. Netzel
Prof. Aug. Martin

Dr. Gluaeppe Beisone

Dr. llildebrandt

Dr 1 hi. 1. i.ra 1 mi
Prof. John Williams

•rof. J. Laxarewitch
U86

Berlin,

Porto Mau-
ri/.io, Italy,

Tubingen,

L'l

Germany,

Milan,

■>.

Strasbourg,

.-!'.»

London,

Aberdeen,
Mississippi,

London,

■s.<>

Leeds, Eng.

■1<\

Breslau,

3«

London,

;;i!

London,
Breslau,

Berlin,

Christiana,

Kiel,

Birmingham,

Baltimore,

Stockholm,
Berlin,

Ut
M

■nil

39 9th
8d

29 2d

33 7th

24 4th

28 3d
39 3d

Buriasco.near 40 1st
Pinarulo, it-,

Kiinigsberg,
KUuigsberg,
London,

Kbaricof;

iiu—ia.

88 U
88 Til,

SO 2d

27 2d

27 Jan 29, Prof. A Stadfeldt

11. Dr K. II. riiampneys; London,

•:■< Mar 80, Dr Joaapo Price, Oatnaaa,

J 1887 Philadelphia.

Copenhagen, 29 1st

4'2 4th

.. Prof. Aug. Breisky
I 1887 !

V « J.r-v.
Vienna,

r.t 1,

Gestation.

Condition of woman at
time of operation.

Besult to woman

9 months

Sac ruptured; legs of foetus Died in 40 hours ; peri
protruding ; peritonitis. tonitis.

Pseudo-labor - pains ; fever ;
cough, emaciation, abdomi-
nal dropsy and oedema of the
extremities.

9th m'th In pseudo-labor 8 days before
the ectopic gestation was re-
cognized

35 weeks J Violent labor ; lame ; rapid
! pulse ; much prostrated.

9 months In extremis; special danger
not stated.

29 or 30
weeks
33 or 34

weeks

40 weeks

9 months
36% wks.
33% "

34% "

35 "

39%

Peritonitis; fecal vomiting
from intestinal obstruction ;
in extremis.

In extremis; emaciated ; jaun-
diced ; oedema of lower ex-
tremities ; almost constant
vomiting ; violent colicky
pains.

Pulse 135, small and weak ;
temperature 97%° ; rupture
of cyst threatened.

Pulse 135; temp. 104.2°; pain;
vomiting; prostration.

Prostrated by pain and re-
peated attacks of vomiting ;
pulse feeble and rapid.

Sac ruptured; peritonitis;
pulse 148 ; fecal vomiting
from intestinal obstruction.

Pulse 100 ; temp. 98.'^° ; urine
highly albuminous.

Vomiting and pain; strength
failing.

Pseudo-labor-pains; fever;
cmesis ; rupture of sac
threatened.

i..-iii.r.il health fair.

Sac ruptured; peritonitis;
atl.-i-teil with gonorrheal
endometritis.

Died in 33 days fron
slow septic poisoning

Died in 20 days fron
subacute peritonitis.

Died in 24 hours of in

ternal hemorrhage.

Died in 29 hours; shocl

and exhaustion .

Died soon after opera
tion ; peritonitis and

hemorrhage.

Died in 88 hours from

collapse.

Died in 4 days of septi
cteniia.

Died in5 hours of heart

elot.
Recovered.

Died in a few hours
collapse from hemor-
rhage.

Died in 22 hours;
hemorrhage

Died in 56 hours ; peri
tonitis and hemor'ge

Died soon after opera
tion. hemorrhage fron
separating placenta.

Died In 36 hours; fever
vomiting, 111.
exhaustion.

Died the next after
noon ; peritonitis.

In a hectic condition ; opera- Died in 16 days; septi
tion of election(?). csemia and hemor

rhage.
9 months Exhausted from severe pains Died on the 4th day
and loss of rest. "prolonged shock."

Pulse 104; temp. 100°, rose to Died in 90 hours; col
130, and 108.6° in 8 hours lapse.

after o|ieriitinn.

'Died in l"> hour-, ex

liausted l.y hemor' ge
Kmac-iated ; sleep prevented ftaorer*/.
by coustant ;«in.

No grave symptoms yet de- DM 08 the 6th day
veloped; paraao-labor>paina. septicemia.
Almost moribund from peri- Died on the loth day

-low peritonitis.
Died in 17'. \ hours;

tonitis.
34% wks. In extremis.

36th wk Thin and auivmir ; ml

atta. ks ..I vomitiiii: and pain
with symptoms of |ieritouitis.

9 months

9 "
7th "
7%"

BafflMring from violent hImIoiu-
ih.il paint ; had had perito-
nitis and jaundi.-e.

Pulse 110; temp normal.

collapse.
Ba aural

/,v onamf,

Died in 38 hours; prob-
ably liemor 1 1
liaturbed bj abdominal Died In

pain.
Sac ruptured; peritonitis ;

greatly i'iim. iat.-.l

septic Intoxication.

Died ill 15 days; hemor-
rhages.

traL

Viable Extrauterine Fcetus.

Result to child.

Remarks.

Lived, male, strung, healthy Operation by long incision ; intestines could not
weeks; not mentioned be replaced until evening of second day; in-
in operator's account of case cUion 9 inches.
..n July 24, 1817, in Rust's
I Magazin.

Lived, cried at once, was a Placenta left in situ ; cord li gated and left hang- Journ. Univer. des Sciences
| large and well-formed fe- ing out of lower end of abdominal wound. | Med., 1816, t. iii. pp. 119-124.
male.

Magazin fur die gasammte
Heilkunde, von Johann X.
Rust, 1818, Bd. iii. S. 1.

3 Lived. Placenta left intact in the iliac fossa, and the ab-

1 dominal wound closed; exfoliation began on
i 6th day.

4 Died in 50 hours; lower ex About two-thirdsof placentaseparated by fingers

treniities deformed. j and scissors and removed; part left bled largely.

5 A 1 i ve, but did not breathe. j Patient, the wife of an intimate friend of the ope-

| rator, was operated upon as a possible, last hope.

I m the second morning ; Placenta torn in the delivery of the foetus; not
removed ; hemorrhage arrested by sponge pres-
sure.
Dr. Greenhalgh was an ardent advocate of Csasar-
ean section, and probably regarded this case 7
as one of little encouragement ; but to be ope-
rated on as a duty.

born asphyxiated ; 17% in.
long.
Died in a few minutes.

8 Lived 6 months; died of bron-
j cho-pneumonia (Black)

9 Died on the second day.

10 Lived; female; died at 11

months of croup.

11 Lived 3 months; hand-fed;

died of inanition.

12 Alive; heart beat 30 to 40

minutes,
i in 6 hours.

14 Died in M hours.

Lived: alive and well at 6
months, then lost sight of.

Died the day after the opera-
tion.

Died in 15 minutes.

Lived, male ; active and well
at last report.

Placenta removed; an intrauterine foetus de-
livered by Cassarean operation ; died in a year
of measles.

Placenta removed ; much blood lost; hemorrhage
ceased from the woman fainting.

Placenta intact ; no cyst ; foetus free in abdominal
cavity ; head under stomach

Placenta incised ; violent hemorrhage ; ligated
and partially removed.

Placenta torn in operation ; torn portion ligated
and removed.

Placenta intact ; became decomposed ; cyst wall
likewise ; 1% pint of blood in abdomen.

Placenta separated in operation, and almost en-
tirely removed ; violent bleeding resulted.

Placenta intact ; cyst plngged with salicylate*!
wool ; considerable blood-loss in operation.

Placenta intact.

Placenta intact ; no bleeding until the 13th day ;

all placenta came away by the 16th day; sepsis

began on 12th day.
Placenta intact : foetus developed between the

luminfeof the right broad ligamant (see case 30)

Lived 18 months ; male; died Placenta intact ; it was found firmly adherent at
of cholera infantum. the autopsy: an intrauterine twin had been

i born 36 days before.
Died in 48 hours. I Placenta divided in operation, with severe hem

I orrhage.
j Alive ; cord pulsated ; did not Placenta removed after ligation at three points,
breathe; had a large en-
cephalocele
Lived ; male; alive and well Placenta intact; located mainly in* right iliac

in May, 1888. ; fossa ; small and malformed.

Lived. j Placenta undisturbed; located deeply down in

the lower pelvis
Alive; asphyxiated beyond Placenta left in place; it was over the fundus

resuscitation. \ uteri and extended into the Douglas space.

Died in a few minutes; heart- Placenta not removed ; located anteriorly be-
j beat 108 before operation ; tween umbilicus and right ant. sup. spinous
head and neck wero cede- process : placenta came away between July 3d
matous. and 14th ; woman well and fat Aug. 14th.

26 days ; wet nursed j Placenta and cyst drawn out, pursed up in the
had two eclamptic seizures; abdominal wound ; ligated : and a large part
died of inanition removed.

Lived 7 months ; died of diar-

I Died soon after operation ; fe- Placenta intact ; cord allowed to bleed ; no cyst,
! male, 15 in long, 21bs lOoz. as in Case 10 ; fcetus with head downward.
Died in 4 hours; female ; ac- Placenta intact ; adherent to uterus, left ovary,
• tive at delivery. broad ligament, right side of pelvis, ilium and

! colon,
j Lived 19 days; died of an Placenta and cyst exsected from fold of broad
abscess of abdominal wall ligament after ligating vessels; placenta lo-
near the umbilicus. cated at superior part of cyst, and subperi-

Neue Zeitschrift fUr Geburt,
1834, Bd. i. S 131

Medicinische Anualen (Heid-
elberg), IMS, Bd. vii. S. 439.

Manuele del parto Meccanico
od Instrumental.' del Lo-
vati, Milano, 18.54. p. 194.

Oaaette Medicals de Stras-
bourg, 1863, t. x. p. 160.

Medical Mirror, Nov. 1864,
p. 689.

New Orleans Med. and Surg.
Journ., 1870, vol xxiii. p.

Trans. Obstet Soc. London,

1873, vol. xv. p. 309.
Trans. Obstet. Soc. London,

1876, vol. xvii. p. 261.

Archiv fUr Gynakol., 1879,
Bd xii:

Trans. Obstet Soc. London,

1878, vol. xx. p. 5.
British Med. Journ., 1877, vol.

ii p. 884.
Archiv. fUr Gynakol , 1879,

Bd. xiv S. 197.

Zeitschrift fiir Geburtshiilfe
und Gynakol , 1880, Bd v.
8. 115.

Norsk Magazin for Laegevi-
denskaben, Juni, 1880,
Tiende, Binde, 6te Hefte,
< x.;

Archiv' fur Gvnakol , 1880,
Bd xvi S. 362.

Obstet Journ. Great Brit and
Ireland, Oct 1880. vol. ii.
p. 577.

Trans. Amer. Gynecol. Soc.,
1882, vol. vi. p. 461.

Hvgeia (Stockholm), 1881,

Vol. xliti. p. 169.
Berlin, klin. Woch., Dec 26,

1881, Bd. XMii. S. 753-775.

Gazetta Medica di Torino,
1881, vol. xxxii. pp. 553-557.

Berlin klin. Woch., July 20,
No. xxix. S. 465.

Opus citatus, S. 465, 1885.

Brit. Med. Journ., Dec. 3,
1887, p. 1213; Trans. Obstet
Soc. London, 1887, vol
xxix. p. 482.

Vrach. St. Petersburg, 1886,
vii. 66, 115; Repertoire Uni-
verselle de Nouvelles
Archives d'Obstet. et de
Gynec., 25 Juil, 18S'

Hospitals Tidende, Sep. 22,
1SK6, p 889.

Trans. Obstet. Soc. London,
1887, vol. xxix. p. 456.

Communicated bv the opera-
tor, April 19, 1887.

Wiener med Woch , 1887, 48,
49, B0

266 HARRIS, EXTRAUTERINE PREGNANCY.

a question in cases in which the child delivered was already dead; until,
after many discouragements, it was discovered nearly a hundred years
ago that it should be left intact, to separate spontaneously if the woman
is to escape death by hemorrhage; and for the last twenty-five years it
has been firmly established that in this class of cases the cyst and
abdomen are to be stitched up together ; the cord brought out at the
lower angle of the wound ; a drainage tube is to be used, and the ab-
dominal cavity to be kept clean by occasional irrigation with warm
water.

When the exsective operation for saving the living ectopic foetus, as
well as the mother, was introduced seventy-five years ago, it was soon
realized that not only was any attempt at peeling off the placenta fatal,
but the non-interference plan, so successful after foetal death, was
attended almost universally with the same result. After nineteen women
out of twenty had died, in the half of whose operations the placenta
had remained intact, Prof. August Martin, of Berlin (Case XXI.),
made a new departure, by which he saved his patient ; and he is now an
advocate of ligating the placental vessels and removing this viscus when-
ever feasible. Unfortunately, the placental location and attachments
are such in many cases that this new plan is not practicable, and the
placenta must be left to exfoliate, with its accompaniments of danger,
under which risk, however, Cases X. and XXV. were saved.

An ectopic placenta may be very much larger and thicker, or much
smaller, than one developed in utero. In general, it is thinner and less
developed and is sometimes divided into lobes, or is only a membranous
and vascular cake. The death of the foetus does not necessarily cause
entire placental death, but the placenta undergoes important vascular
changes after its functional activity ceases with the death of the fetus.
A half-developed foetus in some situations may be attached to a pladWia
which is out of all proportion to the foetal size and age; hence has risen
the idea that the placenta may grow after foetal death ; of which no
absolute proof has as yet been produced, and it does not comport with
the usual teachings of embryology. If the fetus and placenta are mu-
tually dependent upon each other; if the child makes and circulate! its
own blood; and if the placenta is in loco pulmonis until the child can
inhale air and use its lungs instead ; then we cannot see why the phuvnta
should, in any case, become exceptional and grow larger after its functional
lift is do linger called upon. It may be found a gnat deal larger than
it should he some time alter the death of the fetus, but what proof is
there that it was not of this size at the time the (fetal died, and that the
hypertrophic condition did not in a measure cause the death of the
latter? Prof. T. G. Thomas' found in one case that the placenta covered

i Transaction! American Gynecological S... i.-ty, IS84, p. 179.

HARRIS, EXTRAUTERINE PREGNANCY. 2b7

the intra-abdominal centre, and was attached to the ascending, trans-
verse and descending colon, forming an enormous, thick and heavy
growth of several pounds in weight; in fact, it was the largest placenta
he had ever seen ; the foetus had died at maturity, four months before.
Is it probable that this placenta grew after its death? Is it not much
more likely that it was too large for the foetus to be of normal propor-
tion at any stage of gestation?

If all ectopic placentae have originally been tubal, no matter where
they may be found located in the abdominal cavity, as we are asked to
believe, the migratory character of abdominal pregnancies would be
less pronounced. To account for some of the remote localities of the
placenta, we are also asked to credit the hypothesis, that a tubal ovum
may be forced entirely from its attachments through a lacerated vent,
and its placental surface after a migration form a new union for itself
in a remote region of the abdominal cavity and develop to full maturity.
Reasoning analogically, we cannot believe in this as a possibility ; and
we find much less difficulty in accounting for such cases on the hypoth-
esis that they are ab origine abdominal. We know that, for a time at
least, a human ovum is possessed of a certain measure of inherent and
independent life, which admits of its migrating from the ovary along
the Fallopian tube to the uterine cavity and there becoming attached,
after which its inherent life is changed into one of dependence. A
bird's egg, a seed and the bud of a tree are all endowed with an inde-
pendent vitality, lasting longest in the seed. Apply blood-heat to the
egg and the incubative process soon commences ; stop the process by
cooling sufficiently and the embryo dies, because heat has become an
essential of its new dependent existence. As the inherent life is lost,
the egg cannot be made to hatch by renewing the beat ; it now only
hastens its decay. The incubative process must be continued uninter-
ruptedly, or it will end in a failure. Moisture with heat will sprout a
seed ; dry it a second time : Will it then produce a plant ? No, it will
decay. If a human ovum has lost its independent vitality by becoming
attached to the lining of the Fallopian tube or uterus, and is made de-
pendent for existence upon a blood-supply, can it resume this lost inde-
pendent life when it again migrates to form a new home for itself? Will
not the simple separation of an ovum in uiero cause it to die and be
expelled ? Prof. Koeberld, of Strasburg,1 once removed a uterus for a
fibroid tumor, leaving the cervix and the appendages ; the woman re-
covered, with a pervious cervical canal, through which she became
impregnated, with a fatal result. Was this likely to have been a tubal
pregnancy ''. Why is it that within a few years so much doubt has t
cast upon the existence of an original abdominal variety of pregnane v,

1 Dps GroMcccci Extrauterine* : par Theodore Keller, 1872, p. 23.

268 HARRIS, EXTRAUTERINE PREGNANCY.

to explain which away requires much more extravagant hypotheses than
to credit it on the faith of many learned obstetrical writers ?

One year ago, it appeared scarcely possible that an ectopic foetal
growth at full maturity could be entirely removed, as by a form of enu-
cleation, with complete success. But since the report of Case XXX.,
under Prof. Breisky, of Vienna, was issued, it has become a question
whether his process of subperitoneal ligation and exsection cannot be
made available in a fair proportion of intra-peritoneal cases. Prof.
Breisky exsected the whole foetal growth — i. e., amniotic sac, placenta
and child, in a case in which the development took place external to the
peritoneal cavity, between the laminae of the broad ligament, the
placenta being located at the top of the cyst. Prof. Martin, of Berlin,
and Prof. Lazarewitch, of Kharkof, now of St. Petersburg, prepared
the way for this very complete enucleation, by operations 21 and 26,
in which the location and attachments of the placenta prevented the
removal from being as satisfactory in character. By these three
methods of exsection, no doubt in the future, many of the fatal difficul-
ties of the past may be overcome and the women saved. To peel off
the placenta is almost certain to produce death, whether the child be
extracted alive or after it has been some time dead ; but to tie and cut,
carefully and by slow progressive steps, may be done in some cases in
which the attachments of the placenta will admit of it.

The operators who have failed in saving their patients, after the re-
moval of living and viable ectopic foetuses, will be seen, by an examina-
tion of my table, to have been, with a few exceptions, those whose
names have so often appeared in connection with other more hopeful
and successful forms of abdominal surgery. When men, such as
Koeberl6, Greenhalgh, Spiegelberg, Schroder, Lit/maun ami Stadfeldt
were unsuccessful, it may be taken as evidence that there were very
great difficulties to be contended with, either in the condition of the
patient, the anatomical relations of the parts to be removed or both.
What the operators had to contend with will be found in the important
column in the table headed: Condition of the woman at the (mm <»f the
operation. Some may think it unwise to have operated under such
adverse and almost hopeless circumstances; but what better OM be
done until the improved acumen of the student of obstetrical diagnosis
shall fit him to discover the ectopic character of a pregnancy at an
early day? Besides, we are to reflect: 1, that the woman in a 1:
proportion of cases believes herself to be normally pregnant, and does
not call in a physician, or present herself at a maternity, until her health
has failed or a put n< I n-hihor has actually oommenoed; and 2. that she
will not submit to have the living foetus exsected until compelled to do
so by pains, emaciation and other evidences of ill health, and by a con-
sciousness of the fruitless character of her labor.

HARRIS. EXTRAUTERINE PREGNANCY 269

The term operation by election can hardly ever apply to these cases,
for the reason that the surgeon has very little choice in the matter
n called to consider what is to be done ; he must operate, or see the
woman die undelivered. There are cases, and these have been far more
numerous,. in which no opportunity is given to operate until after the
/o-labor has terminated in the death of the foetus; when the whole
character of the case changes, and there may be no occasion for haste,
which may be fatal; but time may be allowed for certain important
alterations in the placenta and its vascular connections, which being
accomplished, its spontaneous separation may be effected with a greatly
reduced risk after foetal extraction.

If the operation after foetal death, provided this has existed for at least
ten week^, can be performed with so much less danger than during its
life ; and if so few children are ultimately saved ; it may be asked :
Why not wait until the child is dead, and then operate? This plausible
and puzzling question once presented itself to a company of three physi-
cians in this city, who were in daily attendance upon a lady in pseudo-
labor. She passed through the labor, the child died, her condition
became apparently more favorable ; they were waiting for the opportune
time, when grave symptoms appeared, followed by her death in half an
hour. In the thirty cases I have tabulated, the condition column does
not give much encouragement for waiting, but rather the contrary.
Many women have, however, in time past escaped all dangers under the
false labor, and have even carried the dead foetus for years in compara-
tive health ; or have had it removed by abdominal or vaginal section,
because of some physical disability resulting from it. But such cases
rarely fall into the care of a fully competent obstetrician during the
labor, and the attendant called in expects the woman to deliver herself,
and waits for this event, until too late to save the foetus.

A realization of the dangers of ectopic pregnancy has given rise to a
desire to arrest the development of the foetus at an early day ; and after
various plans have been tried, two are still considered worthy of confi-
dence, viz., faradization or galvanism, to destroy the fcetus ; and exsec-
tion of the entire cyst to accomplish the same end more effectually.
Gynecologists are divided in opinion as to the choice to be made of the
two plans, in any given case before rupture, one party claiming that
electrical foeticide is not only dangerous as a method in itself, but leaves
the fetus in loco to give subsequent trouble ; and, at the same time,
that extirpating the foetal cyst, generally Fallopian, can be done at a
moderate degree of risk, and will leave the woman free from the foreign
growth as an element of danger. The electrical advocate states that
his method is devoid of danger ; that the foetal mass becomes absorbed ;
and that the health of the woman in not endangered by the remnant of
the foetal growth. He, at the same time, also regards the proposition to

270 HARRIS, EXTRAUTERINE PREGNANCY.

exsect as one of much greater peril, aud one that may in some instances
be attended with insurmountable difficulties.

Whichever plan of operation is selected, it is essential that a correct
diagnosis should be made, and the character of any discovered abnormal
growth decided upon before it is commenced. To make a reliable differ-
ential diagnosis in a case of ectopic pregnancy is not a simple matter,
and can rarely be done in a few minutes, for not only must every sensible
and sympathetic sign be duly weighed, but the history of the case taken
and considered in connection therewith. By these means a chain of
evidence may be obtained that will show by exclusion how impossible
it is that a given intrapelvic growth discovered by palpation can be other
than a product of impregnation. To make such a diagnosis is much
more the work of an obstetrician than of a surgical student. Mr. Tait
cannot believe that this can be done in more than one case out of three ;
but many obstetrical observers hold a very different opinion, particu-
larly in this country, where special studies have been made of many
cases prior to rupture. This accident may occur too early to have been
preceded by any symptoms to excite attention, as has twice happened in
this city, where the ovum could not have been developed beyond three
weeks, or between the end of one menstrual epoch and the beginning of
the next one. But in the average of cases time enough is given before
laceration to produce size of growth for palpation, and symptoms,
sensible and sympathetic, now well known as characteristic of ectopic
gestation when taken in connection with a history indicative of this
condition.

Regarding the question of preference from a neutral standpoint, I
am prepared to examine the two named foeticidal methods upon their
relative merits as thus far exhibited, first stating my belief, that if it is
morally proper to exsect the foetal mass, it is equally so to destroy the
foetus in situ. Two important questions naturally arise, viz. : 1. Which
is the more immediately dangerous — electric foeticide, or exsection of the
ectopic foetal mass? 2. Is there any remote danger to be apprehended
from the presence of the dead foetus ? These can only be answered by
a long array of facts which have not yet been produced. So fur as
known to me, the electric foeticidal operation has been performed in the
United States and Canada forty times, with one death, and in that case
a second attack of hemorrhage took place from a large superficial
artery in the cyst wall, which vessel had bled nine days before until
the patient bore the evidences of it. Exsection of the entire growth
was certainly indicated here. Although laparotomy can be performed
a i,'reat many times in succession without a death, as witness the results
of ovariotomy and oophorectomy umhr some operators: Is it at all
likely that this more difficult and complex operation can be undertaken

HARRIS, EXTRAUTERINE PREGNANCY. li71

with the same degree of impunity ? If all ectopic foetal cysts were
favorably located, and their existence discovered at an early date, no
doubt a skilful operator might be able to exsect them with a moderate
ree of mortality ; but such is not the case, and the knife must be
used at times under circumstances of great difficulty and danger. Prof.
August Martin, of Berlin, advocates the exsective operation at all
periods, and has performed it quite a number of times with marvellous
success, even up to seven months of gestation in one case (XXI., of
Table). But there are few Prof. Martin's ; and ectopic mishaps will
occur in places in which even the average surgical skill cannot be com-
manded. Theoretically, there are many reasons for preferring exsection
to faradization and galvanism, and I, for one, should be glad to be
convinced that the immediate removal of the foetus from the pelvic or
abdominal cavity can be accomplished, even in our large cities, or at
locations where skill can be commanded, with but a trifling degree of
danger.

The second question can only be answered by a collective record of
the subsequent medical histories of the forty-five or fifty women in
whom electric-killed foetuses have become foreign bodies, to be the pro-
ducers of much, little or no disturbance. That a very young foetus is
capable of being almost entirely absorbed, after it has been destroyed
bv electricity, appears probable from careful explorations and from ex-
periments on the lower animals ; but what are the capabilities for pro-
ducing injury of a dead foetus of three or four months' development?
a will be taken by a competent investigator for ascertaining the
secondary dangers experienced and present degree of health exhibited
by the women in whom electrical foeticide has been performed. It may
be urged that proof of the existence of a fatal growth has not been well
established in many cases ; but this is a question of, doubt, which simply
brings in dispute the ability of a number of well-known American ob-
stetricians and gynecological practitioners to make a differential diag-
nosis, which they claim they can do. Many who have questioned this
ability are, at the same time, advocates of the early exsective opera-
tion. Do they propose to operate upon a conjectural diagnosis, and
determine the true nature of the growth by its examination after re-
moval? It is quite possible for an abdominal surgeon of large experi-
ence to have had his attention very little directed to cases of ectopic
gestation prior to rupture, and to the signs which indicate such a condi-
tion to the obstetrical observer : Is he wise in disputing the ability of
men, who, by a special study and larger field of observation, claim to
be able to do what he feels that he cannot ? Tactile sense is of great
value in abdominal surgery, but of itself is of little use in determining
a growth to be of foetal origin.

272 HARRIS, EXTRAUTERINE PREGNANCY.

Electricity and exsection are both on trial, the former in the advance
from the number of tests. It has superseded the more dangerous ex-
pedients of aspiration and toxic injection, and has now only the new
rival of exsection, which promises to be fully tried in the near future.
We are satisfied that electricity will kill the foetus ; that when dead it
will diminish in size, and the fluid in the cyst be absorbed ; but here we
stop for the present until the subsequent history of the cases has been
looked up and reported.

Thus far the innocence of the exsective operation is largely hypo-
thetical except as to the cases of Martin and Veit, of Berlin.1 We
have in this country a number of bold abdominal operators, chiefly
young men, who strongly advocate exsection, and who I hope will be
able to prove by actual results the claims they have made for this in-
viting substitute : inviting, because it at once eradicates what electricity
only destroys and retains, it may be to give trouble at a later day.

The earlier exsection is attempted, the more easy it is to perform ; but
when adhesions begin to form the difficulties of removal commence, and
these grow and increase more and more with every additional month of
development. In the later cases the abdomen must be largely incised ;
its cavity should be illuminated by an electric light ; no parts should be
peeled off or adhesions separated by the fingers ; bloodvessels and
vascular parts are to be tied and then cut step by step until the placenta
is slowly separated. The cyst may not require such care in removal, as
its adhesions may be the result of circumscribed peritonitis ; but there
are cases in which the cyst and its connections will be found dangerously
vascular, and only to be treated as the placenta requires. The whole
mass must be removed, or secondary hemorrhage will almost certainly
ensue with a fatal result. Until the abdomen is opened the operator
can form only a conjectural idea of the difficulties he may have to
encounter, if the foetus is advanced to or beyond the fourth month, as
everything will depend upon the location and vascular connections of
the placenta. In the later months the operation will be little tan difficult
than when the foetus is at full maturity, and it may become a question
whether two lives cannot be saved by waiting until the foetus is fully
viable. Much will depend upon the condition of the woman, who may
not be in a state of health to wait; in which event the operation should
be performed at once, and the exsection made as entire as practicable. As
t he electrical advocates do not recommend their system for cases after the
fourth mi int h, exsection must be the rule, and the time of choice that
which promises most favorably.

1 Velt hu operated •e»rii timm prior to raptsn, mul kiiv.mI ill of tli<- eMM, It will be of interest to
know what «vmptom« indicated the necemlty for the operation*, and whether he was able to ninke
■atiBfnrtory diagnoses before opening the abdoim-n.

HARRIS, EXTRAUTERINE PREGNANCY 273

Thus far I have directed attention to exsection by abdominal incision
only ; but it may not always be advisable to operate in this way, for the
reason that nature may point to the vagina as a more eligible outlet. If
the fetus presents by the head, behind or at the side of the cervix, and
the covering parts are distended over it, this may be taken as an indica-
tion that delivery should be accomplished by vaginal incision, and, if far
advanced, by the forceps. I have in my possession a record also of
thirty vaginal deliveries, in only two of which was the fetus living and
viable, and in both instances the child and mother were saved.1 These
thirty cases include five in which rupture into the vagina had taken
place, and ten in which the fetus had been carried from eleven months
to twelve years. Of the whole thirty women, twenty recovered. Six were
operated upon at full term, four of the fetuses being dead, and five of
the women, with the two living children already mentioned, were saved.
In the two operations of Drs. King and Mathieson, in which the women
and children were saved, the placenta was peeled off and removed
without serious hemorrhage, a solution of perchloride of iron being
applied as a styptic in the latter ; but an attempt to do the same, in a
pregnancy of about three and one-half months, by Prof. T. Gaillard
Thomas, of New York, placed the life of the woman in great jeopardy,
and he was forced to desist.1

Two forms of ectopic gestation appear distinguishable in these cases,
viz.. the subperitoneal of Dezeimeris, to which the King and Mathieson
cases are believed to have belonged ; and the intraperitoneal, also origin-
ally tubal, but developing within the pelvic peritoneum and upward
in the abdominal cavity. In the latter variety there may or may not
be an enveloping fetal cyst. In a case operated upon in this city by
the late Dr. Albert H. Smith,3 the intestines were united to produce a
form of sac, which broke open at the top, and the fetus, which had
escaped, was found beneath the transverse colon; the result was fatal.
In another Philadelphia case, in which the fetus was dead and weighed
ten pounds, and the woman was doing well for a week, a mild antiseptic
wash was used (as the discharges were slightly fetid), which entered the
peritoneal cavity through an open cyst and produced violent peritonitis,
resulting in rapid death. The possibility of the cyst being imperfect
should oblige an operator to use only warm distilled water for intra-
abdominal irrigation in these cases.

The vagina should be opened by puncture and tearing to avoid the
risk of hemorrhage, or by the therrao-cautery knife, except in cases

1 Xew York Repository, 1817, pp. 388-394. Transactions Obstetrical Society, London, toI. xxyI., for
1884, pp. 561-569.
» New York Medical Journal, 1875, pp. 561-669.
* American Journal of Obstetrics, 1878, toI. xi. p. 825.

274 HARRIS, EXTRAUTERINE PREGNANCY.

in which it has become much thinned by continued pressure, when it may
be incised. As this form of operation will not admit of the sub-
ligation and exsection of the placenta for the want of space and light,
it will be wiser to wait until spontaneous separation takes place.

The primitive operation of exsection by abdominal incision, as per-
formed with such success by Dr. J. Veit, of Berlin, must take precedence
of that made suddenly necessary by the bursting of the cyst, as intro-
duced by Mr. Tait ; for the reason that the performance of the first will
prevent the possibility of an accident, which often produces death before
an operation for the arrest of the hemorrhage can be performed. The
contest between exsection and electricity in cases of ectopic pregnancy
of two months or ten weeks standing, will in all probability end largely
in favor of the former. It has become a popular measure in Germany,
where the other has never met with any favor, and it may eventually
be regarded as a promising method of treatment in the United States.
The question of relative fatality no doubt favors the side of electricity ;
but there are other points to be considered, which may in a measure
outweigh the danger of a fatal issue, if in the future this degree of risk
be shown, as the result of a series of cases, to be of moderate measure.
The antagonism between very early exsection and the use of electricity
must in time diminish, as there must be circumstances which will lead
unprejudiced operators to select one or the other method in a given case.
Men of surgical inclinations will no doubt prefer the knife to electricity,
and vice versa. The question of the possibility of diagnosis, claimed as
non-proven by the results of electricity, will be settled beyond peradven-
ture when the knife and the eye are brought to bear in establishing
evidence.

329 South Twelfth St., Pint, vhki.imiia.

REVIEWS.

System of Obstetrics. By American' Authors. Edited by Barton
Cooke Hirst, M.D., Associate Professor of Obstetrics in the University of
Pennsylvania, etc. Vol. I. Illustrated with a colored plate and three
hundred wood-cuts. 8vo. pp. 808. Philadelphia: Lea Brothers & Co.,
1888.

It is safe to say that the statistical method in literature will hardly
hold, and it is, therefore, unfair to say that four elaborate, painstaking,
earnest volumes by American authors on the same subject in six years,
constitute a literature. Lusk, Parvin and the System of Obstetrics by
American Author* mean, however, more than four volumes. They imply
a well-sustained energy of productive work, and prove the prevalence
of a spirit of inquiry and awakened interest.

The idea of being in a certain sense American, as implied in the title,
we believe to be well justified. Nationality is something more than is
defined by the color of the skin and in facial expression. It is defined
in the pelvis of the woman ; and, sexually, from the short perineum of
the African to the long perineum and high vulva of the European to
those higher sexual traits of mind, we find racial differences existing
with the corresponding outgrowth in the practice of obstetric art. It
may be said that racially that there is no such thing as an American.
H are cosmopolitan. All strains of blood are mingled to produce our
peculiar people. The emotional intensity, the social life, the education,
the climate, the food develop a peculiar race of women with well-defined
racial traits. Three or four generations are required to graft these traits
upon the emigrant stock. Obstetrically speaking, there are national
ditferences that have made their mark upon the art if not upon the
science.

In the art of obstetrics our physicians are not instrumentalists, yet here
is the home of the low forceps operation. One may practise a lifetime
in this country and never meet with a Tarnier forceps ; but to relieve a
• d-out woman by helping a head over a perineum is nearly a routine
matter. We constantly hear gynecologists say that foreign women are
different from ours in the way they bear the more severe operations ; but
it is said half in protest, half in earnest ; but we say it soberly in posi-
tive conviction that we are right and able to prove it, if this was the
proper place.

In former reviews of American obstetrical Avorks this journal has
called attention to what we believe to be matters of practice peculiar to
the art as it exists among us. This was more marked in Parvin's book
than in that of Lusk. who was imbued with the German idea; but even
in the hitter's splendid volume we find many things that we may call
Americanisms in practice.

276 REVIEWS.

The volume opens with an historical notice of obstetrics by an author
especially well equipped to give the subject intelligent treatment, Dr. G.
J. Englemann, of St. Louis. The author has the correct idea of the
philosophy of history. It is events, not men, that make history. The
man is a mere actor, who oftentimes cannot even be called a factor, for
behind him lies the great accumulated current of thought and of moral
force called truth, which changes the course of events in science as well
as in dynasties. The truth of this underlying motive in history is
proved by the science of obstetrics. Semmelweiss laid the foundation
for modern antiseptic obstetrics, yet it needed a greater than he to make
it the obstetric law of the world. J his idea Dr. Englemann carries out
in his history.

The author divides his subject into the empirical or natural obstetrics,
embracing the primitive or intuitive and the religious period. This age
terminates in 1550, when the second, or scientific obstetrics begins.
Podalic version divides this period of enlightenment from the dark :
of the past. The author defines it as the period of development, and
recognizes three stages: the podalic version described by Pare | L550 :
second, the obstetric forceps (1647 to 1745) ; and third, the development
of the forceps (1745 to 1800, and the physiological period, or " perfec-
tion," as the author calls it, from 1801 to 1888). These various divisions
culminate in the scientific period from 1870 to 1888. The seventy
pages needed to describe the development and history of obstetrics are
replete with facts and dates, and comprise one of the most carefully
written sections in the book.

The second section is upon "The Physiology and Histology of Ovula-
tion, Menstruation and Fertilization : The Development of the Embryo,"
by Dr. H. Newell Martin, of Baltimore. A lengthy exposition is given
of the physiology and histology of the ovary, of ovulation and of men*
struation. Upon these subjects the author is simply orthodox. He has
given some new illustrations, which give the text a fresh appearance
and are a welcome addition to the time-bound cuts with which we are so
familiar in obstetrical works. The natural history of the fertilisation
of the ovum and the painstaking and illustrative way in which the spe-
cial development of the organs is traced make very clear and interesting
reading. As much of the material is gathered from original sources
and from works rarely within the reach of the general reader, this addi-
tion will be a very useful one.

The editor, Dr. Hirst, disposes ofthe next subject: "The Foetus; its
Physiology and Pathology. The section is devoted to a review of the
development, anomalies and diseases of the foetal appendages. The
amniotic fluid is believed by the author to be due to Doth mother and
child, as the experiments of Xnntz and Gusserow prove, and errors in

both mother ana fetus contribute to diseases of this fluid. The mem-
brane itself, in cases of faulty development, may form amniotic bands,
the cause of extensive adhesions between the amnion and the fetus which
may result in serious deformities, such as eventration or anencephalus,
by preventing the proper arching over of the body cavities by the fetal
skin. As a singular e\ idenoe of the oorrelatioc between tissues, the com-
position of these bands closely resembles that of those due to plastic
inflammation of serous membranes generally. In the latter part of
pregnancy the amnion may burst, the life of the ovum being preserved
by the sac of the chorion. The active fcetal movements may roll up

HIKST, SYSTEM OF OBSTETRICS. 277

the amnion into cords which become entangled with the foetus or the
umbilical cord and cut oft* the circulation.

W "c will note but one morbid condition, that of syphilis of the pla-
a. Only as late as 1873 Friinkel gave us something definite in the
histology of this condition. The deforming granular hyperplasia and
hypertrophy of the placental villi were the most frequent forms of
placental syphilis. These conditions had been previously described by
Ercolani, without associating them with a syphilitic lesion. This infiltra-
tion of the villi with granulation cells, and their consequent increase in
size and distortion, are characteristic of syphilis, and are diagnostic
signs; but we may go further than this, and trace the source of the
virus. If the ovum is infected through the male, the placenta, if dis-
eased at all, will show the granulation cell infiltration of the villi. If
the mother is infected during the fruitful coitus, there will be great over-
growth of the decidual cells or of the connective tissue. If the mother
Uilitic before conception, the placenta shows gummatic deposits.

The diseases of the foetus in utero, both acute aud chronic, conclude the

ion, with considerable space given to abortion and premature labor.

Parturition is given no consideration by Dr. Hirst, and it is really

remarkable how closely the various authors adhere to the division of

their work.

Dr. W. W. Jaggard follows upon the " Physiology of Pregnancy."
He takes up the changes of a normal character upon the organs of the
body, and traces them through the course of the pregnancy. Consider-
able space is given to uterine evolution, and the conflicting views of
Miiller, Baudl, Henle and others are explained with great clearness.
Thn portion comprises, also, the diagnosis of pregnancy.

We have space but for a -short quotation; that relating to the so-
called Hegar's sign of pregnancy. Dr. Jaggard's description is worth
remembering, because no two writers that we have seen describe either
the sign or the manipulation necessary to elicit it in the same way.

" The lower uterine segment becomes softer and more compressible in con-
with the thick dense cervix below and the corpus above. These altera-
tions are most marked in the median section of the lower uterine segment,
while the borders remain relatively dense, appearing at times like cords. . . .
To elicit the sign under discussion, the index finger of either hand is intro-
duced within the rectum, while the thumb of the same hand is placed upon
the vaginal portion. The index finger passes above the utero-sacral liga-
ments, marking the boundary between the cervix and the lower uterine seg-
mcnt, into the pocket of the sphincter ani-tertius. If the aperture of the
sphincter ani-tertius is not readily found, one-fourth of a litre of lukewarm
water injected into the rectum facilitates the search. The other hand placed
upon the abdomen, presses the uterus downward against the finger in the
rectum, when the lower uterine segment, the cervix and the corpus uteri can
be easily touched." •

Dr. Jaggard's comment upon this is a very proper one :

"Any attempt to fix the limitations and to point out the fallacies to which
this sign is liable at present would be premature. The facts in our possession
as to its occurrence and diagnostic significance are entirely too meagre to war-
rant generalizations. In passing, it may be said that Compes failed to detect
the sign in one case of early pregnancy, and observed phenomena somewhat
similar in cases of retroversion of the uterus. Obscure and confused notions
as to the objective changes embraced under Hegar's sign have rendered
invalid the conclusions of certain American authors."

278 REVIEWS.

In connection with what was said at the opening of this review touch-
ing some peculiarities in practice that may be regarded as American-
isms, that the high forceps operation was rarely called for in native
women, but that it was a very common and growing practice to help
the head over the perineum in exhausted women, we may quote the fol-
lowing from Dr. Jaggard :

"It is not always necessary, nor is it always expedient, to insist upon an
elaborate investigation of the dimensions of the pelvis. In the United States
there exists a very decided presumption that the native-born woman has a
normal pelvis."

To Dr. Jaggard we are also indebted for the contribution upon " The
Pathology of Pregnancy." Much valuable matter is given in a concise
and readable form, and the author is to be congratulated in presenting
one of the best written sections in the work.

Dr. Samuel C. Busey, of Washington, D. C, follows on the " Physio-
logical and Clinical Phenomena of Natural Labor." The author has
written a thoroughly conventional chapter. On the conduct of labor
the author disposes of antisepsis in a paragraph of a dozen lines. There
is no doubt about the opinion of Dr. Busey upon the subject of anti-
sepsis. All preparations of the patient, he says,

" must be supplemented by an equally complete preparation for, and assiduous
application of the principles and practices of, antiseptic midwifery. Inex-
cusable neglect, and inefficient and careless administration of the well-known
rules and recognized appliances of obstetric antisepsis must, in view of their
admitted value, be regarded as criminal."

If by " well-known" the author means generally accepted and practised,
he is certainly wrong. If by " recognized appliances " he means that the
methods of antiseptic obstetrics are all settled, he is equally wrong. If
by "admitted value" he means that both the methods and value of anti-
sepsis so applied are admitted generally or in equal degree, he is again
wrong. This whole matter is yet on trial among thousands of medical
men. It is not even the general custom in private practice. Every
man who believes in antiseptic midwifery must become, in a certain
sense, a missionary. He must spread the gospel of purity in the lying-in
room, both public and private. Dr. Busey has not performed his whole
duty in this matter. Twelve lines of advice will not convert a careless
or a sceptical man to the belief and practice of antisepsis. It is methods
not advice that we need. The author is contributing an important
chapter to an encyclopaedic work, that gave both space and opportunity
fur detail, and to which the reader is entitled.

Dr. R. A. F. Penrose, of Philadelphia, contributes to the "Mechan-
ism of Labor and the Treatment of Labor baaed on the Mechanism."
This relates to normal labor. in all fatal position! in which natural
fores are concerned to accomplish the expulsion of the child. It is very
clearly written and well illustrated, many of the illustrations being new.
The careful avoidance of any description of obstetrical operations is at
times embarrassing to the author, due to the careful manner in which
the editor has held his contributors in hand.

This section is concluded by the editor on the " Mechanism of the
Third Stage of Labor." He says,

"In sharp contrast to our definite knowledge of the mechanics] laws that
govern the expulsion of the foetus stands our uncertainty in regard to tin-

BILLINGS, VITAL STATISTICS OF UNITED STATES. 279

method by which the placenta is separated from the uterus and is expelled
through the birth-canal."

The Editor's theory is that the

" placenta is not separated at once, even when the foetus has entirely vacated
the uterine cavity and the uterus has been very much reduced in size. The
spongy placental mass can follow the retraction of the uterine wall until the
solid villi are brought into actual contact with one another and the whole
placenta forms a perfectly solid mass. As soon as that point is reached, the
slightest additional contraction of the uterine muscle, with the smallest de-
crease in the area of the placental site, springs off instantly the entire placental
mass, which can no longer be compressed."

The theory is a reasonable one, and in that respect is an advanoe on
many that have been offered.

One of the most carefully and laboriously written contributions to the
volume is that of Dr. J. C. Reeve, of Dayton, Ohio, " On the Use of
Anaesthetics in Labor." So far as the reviewer is familiar with the sub-
ject, it forms one of the most complete monographs in the language and
is particularly rich in historical references.

Dr. Theophilus Parvin concludes the volume with "Anomalies of the
Forces in Labor." Errors in uterine action, tumors, pelvic distortions
and various anomalies in foetal development and their relation to the
mechanism of labor are presented at length, in the usual clear and care-
ful manner of the author.

Lack of space obliges us to omit many points that deserve attention.
There can be no doubt that the work will earn an important place in the
literature of the subject ; and if the second volume equals the first in its
wide range and painstaking treatment, it will stand second to none in
any language. E. V. de W.

Report on the Mortality and Vital Statistics of the United
States as returned at the Tenth Census (June 1, 1880). By John
S. Billings, Surgeon, U. S. Army. Part I. 4to. pp. lxiii. 767. Wash-
ington : Government Printing Office, 1885. Part II. 4to. pp. clviii. 803.
Washington: Government Printing Office, 1886.

The present volumes, which are the eleventh and twelfth of the quarto
series comprising the final report of the tenth census of the United
States, are devoted entirely to the subjects of mortality and vital
statistics for the year ending June 1, 1880. They have been compiled
according to a scheme projected by Surgeon John S. Billings, who has
with untiring zeal and industry personally supervised the work from
the beginning to the end. As a result of this labor we have a report
which is far superior in completeness of data and accuracy of details to
any of its predecessors. That the data are still very imperfect no one
knows better than Dr. Billings, who has worked most assiduously to
obtain the best results possible under the existing laws governing the
taking of the census.

Part 1. is taken up entirely with the statistics of mortality. A
deficiency in the returns of the enumerators having been anticipated,

280 REVIEWS.

an attempt was made to obtain a more complete record of deaths than
had heretofore been furnished, by securing the voluntary cooperation of
the medical profession of the country. By this effort, 61,020 deaths
have been recorded, which had not been reported by the enumerators.
As a further aid in accomplishing the same object, the official records of
deaths in a few States and a number of cities which have registration
laws have been copied and made use of instead of the data collected by
the enumerators. As these data are very nearly accurate, they have
also been made use of in obtaining an approximate estimate of the
amount of deficiency in the enumerator's returns. Such an estimate is
very necessary, for it is known that the data are very incomplete, yet
scarcely more so than similar data published by other countries. It
must not be inferred from this incompleteness that the census data are
of little value, for they are comparable with those of foreign countries,
and, moreover, they are in fact the only data procurable for parts of
the country which have no registration. An accurate system cannot be
obtained at once, but each census should show signs of progress, as this
census does, especially in the improvement in the methods of tabulation,
which being pursued will afford valuable results when more complete
<lat:i are obtainable under better laws.

As already intimated, the form of tabulation differs somewhat from
that of other censuses, but care has been taken in selecting the combi-
nations to make them comparable with the statistics of other years and
of other countries. The data, with certain necessary tables of ratios
and proportions, are presented without attempting to draw conclusions
from them, the study of the figures being left to those who are specially
interested in such research.

The county has been selected as the unit of locality instead of the
State, as in previous censuses, a change which permits of many inter-
esting and useful comparisons, heretofore impracticable. Groups of
counties within the limits of the State form State Groups. These are
consolidated into States, and also combined into what have been called
Grand Groups, having boundaries determined by topographical features
and not by State lines. The reports of 'deaths in fifty of the largest
cities have been separately compiled, in order to make possible a com-
parison between rural and urban mortality. These various compilations
are presented in twelve tables, which, with an index, cover 767 pa

The mortality rate of the United States for the census year is 15.09
per 1000 of surviving population, which is an increase over the death"

rates of former censuses. Tins increase must not be regarded as repre-
senting an actual increase in the number of deaths in proportion to the

living population, but rather as indicating a more complete collection of

the data upon which the death-rate is based'; and yet there is proof of a

deficiency still existing, as is shown by a careful study of the statistics of

States and cities in which the registration is probably very nearly accu-
rate. From these and other data. Dr. Billings has calculated the pro-
portionate amount of deficiency in the enumerator's returns, and with
correction places the death rate for the whole country at 18 per
1000 of surviving population. The death-rate thus obtained, which is

probably very nearly correct, compares favorably with that of all other
civilized countries.

The remaining part of the introduction to Part I. discusses the sub-
jects of sex in relation to deaths, relations of age to deaths, relations of

BILLINGS, VITAL STATISTICS OF UNITED STATES. 281

color and race, etc., to deaths, and month or season in relation to deaths.
The points of interest are so concisely stated that it is impossible to
abridge the matter without detracting from its value.

Part II. is by far the more interesting of the volumes on Mortality
and Vital Statistics. The introduction, covering 147 pages, presents the
iltfl of a careful study of the following subjects: location in relation
to births, causes of death, morbidity or sick rates, births, birth-rates
and lite tables, ages of living population. To these is appended a brief
chapter of conclusions and recommendations. The text is illustrated
by 21 handsome colored maps. Diagrams are used whenever such illus-
trations aid in the elucidation of the text.

The reft of the volume, 791 pages, is taken up with 54 tables furnishing
data on the various subjects epitomized in the introduction. Accom-
panying part second is a book of plates and diagrams to illustrate
approximate life tables for certain States and cities contained in volume
twelfth of the census.

Consumption stands first upon the list of the principal causes of death
for the census year, and then follow, in the order of their frequency,
pneumonia, diphtheria, heart disease, cholera infantum and enteric fever.
Scarlet fever stauds eleventh on the list. It caused 16,388 deaths ; of
this number 8181 were males, and 8207 were females. The mean age
of those reported dying of this disease in the census year was five years.
Scarlet fever caused a larger proportion of deaths in the large cities
than in the rest of the country. Its propagation being due to a con-
tagion, it is not directly influenced by season or weather, locality, con-
dition of soil or elevation of locality.

Enteric fever caused 30.19 per 1000 deaths from all causes, which is
a -mailer proportion than that noted in the preceding censuses. The
greater part of the deaths occurred between the ages of 5 and 40 years,
the mean age at death being 27 years. One fact stands out prominently,
namely, that enteric fever prevails to a much less extent in cities than
in other parts of the country. In the 50 largest cities, this disease caused
16.7 in each 1000 deaths from all causes, while in the rest of the country
it caused 36 per 1000. August, September and October were the months
in which the greatest number of deaths occurred in 31 registration cities.

The number of deaths from diphtheria largely exceeds that of the two
preceding censuses, while the deaths from croup have slightly decreased.
A small part of the increase of deaths from diphtheria may be attributed
to the fact that physicians now report as diphtheria cases which many
years ago would have been returned as croup. It is, however, very evi-
dent that diphtheria has been on the increase for several years past,
especially in the northern portions of the United States. The mortality
from both croup and diphtheria is greater in the rural districts than in
the large cities.

E nil pains has been taken to present the census data with regard
to diphtheria as fully as possible. A number of colored maps showing
the distribution of deaths by counties, in the northern and eastern por-
tions of the country, convey at a glance much information on the relative
prevalence of this disease in different localities, which has hitherto been
defective. An examination of these maps, as Dr. Billings points out,
will indicate " that the disease cannot be due to any peculiarity of
climate, of geological formations, of topography or of methods of filth
disposal."

VOt. 96, HO. 3.— SEPTEMBER, 1888. 19

282 REVIEWS.

The distribution of " diarrhceal diseases " is more uniform than the
affections specially mentioned above. These diseases caused a greater
number of deaths in the large cities than in the rural districts. This
may be accounted for by the fact that the majority of deaths from these
causes are among children under five years of age, and that these dis-
eases are more prevalent among young children in large cities than in
the country. In thirty-one registration districts, the greatest number of
deaths occurred in the summer months, the highest mortality being
reached in July.

As might be expected, consumption stands first upon the list of dis-
eases in the order of their frequency. It caused 12,059 deaths in every
100,000 from all causes. The mean age at death was thirty-seven years.
The comparison of deaths by sex shows the disease to be the more fre-
quent in females than in males. The proportion of deaths is greatest in
the large cities, and slightly greater in the colored race than in the white.
The geographical distribution of consumption, as illustrated by map
twelve, shows the greatest prevalence of the disease in the New England
and Middle States, the Middle Atlantic Coast, the Ohio Valley, western
part of Kentucky, the central part of Tennessee and on the Coast of
California. The distribution of deaths is quite uniform throughout the
year, though in the winter and spring months there is an excess of deaths,
the maximum being reached in March.

Pneumonia, a term which probably includes a number of distinct dis-
eases, after consumption, caused the greatest number of deaths. It is a
disease of all ages, but is especially fatal in early and in advanced life.
There was an excess of mortality in males, and a relatively greater mor-
tality in the colored race. The disease was least prevalent in the coast
regions, and generally more prevalent in the south and west than in
the north and east. The winter and spring months were the seasons
of the greatest prevalence. The proportion of deaths was greater in the
rural districts than in the large cities.

The deaths from childbirth for the whole country were 3.57 per 1000
births. The mortality from this cause was greater in the rural districts
than in the large cities, and about twice as great in relation to the
deaths from known causes in the colored female as it is in the white.
The greatest proportion of deaths from childbirth occurred at ages
between twenty and twenty-five years.

Cancer, a disease which is apparently on the increase in civilized coun-
trirs, has allotted to it considerable space for presenting deductions
drawn from the very full data furnished by the census. It is shown
that, cancer is a disease which ailects all ages, but the proportion of
deaths increases with advancing years. Among females the proportion
of deaths increases until between the ages of fifty and fifty-five years,
when it reaches its maximum ; among males it increases until between
lixty and sixty-five years, when the proportion is greatest. The great
ess of deaths from cancer in females is marked after the age of twenty,
and less marked after the age of sixty-five. The tendency to cancer in
the colored race is shown to be very much less than it is in the white
race.

As cancer is a disease the mortality from which increases with
advancing years, a large proportion of deaths from this cause in any
given locality indicates to a certain extent that the locality is a healthful

BILLINGS, VITAL STATISTICS OF UNITED STATES. 283

ami ■ 1' in.: settled one, and that a large proportion of the inhabitants
attain advanced age. A comparison of the maps showing the geograph-
ical distribution of cancer and of old age will make this point clear.

The deaths in the whole United States for the Census year from
hydrophobia were 80; from lightning, 300; and from leprosy, 16; thus
showing how infrequently death takes place from these causes.

the first time in the history of the United States Census, an
attempt has been made to obtain morbidity or sick rates. A portion
of the country was selected sufficiently large to give a fair indication
of the relative proportion of the sick of the whole population over fifteen
years of age in every 1000 living on a given day, which was June 1st.
The result shows the proportion to have been 12.75 per 1000 living,
which appears to be a fairly accurate proportion, judging from the data
furnished from mutual benefit societies in this and other countries, and
the specially reliable data of the State of Rhode Island. If the annual
death rate is taken at 18 per 1000, the average number of persons above
fifteen years constantly sick is 36 per 1000 of living population.

Births, birth-rates and life-tables are presented in section tenth. The
total number of births collected for the census year was 1,577.173, and
the birth-rate was 31.4 per 1000 of the living population. This is about
15 ]>er cent, below the true figures, which Dr. Billings has carefully esti-
mated to be about 36 per 1000 for the whole country. For the period,
•'-1880, the mean annual birth-rates for England and Wales was
35.4 per 1000; for the German Empire, 39.3; for Austria, 39.1 ; and
for Denmark, 31.9. The corrected returns for the United States com-
pare favorably with the accurate data of the countries above mentioned.

Of the totai number of births, 806,866 were males, and 770,307 were
females, or 1047 males to each 1000 females. The birth-rate was
greater in the colored race than in the white, and highest in the southern
- and in the northwest.

Approximate life-tables have been prepared for a number of cities in
different parts of the country and for the States of Massachusetts and
New Jersey, the method employed by Dr. Farr having been adopted.
The method of Dr. Humphreys was also used in connection with the
data of Massachusetts and New Jersey. From these tables diagrams
have been prepared, some of them being printed on semi-transparent

Eaper, so that, by placing them one above the other, a comparison may
e made of the different localities with respect to the proportional change
at each age.

An interesting and valuable table is furnished by which comparison
may be made of the expectation of life thus calculated with the data
furnished by the English Life-table, No. 3, that founded on the experi-
ence of 30 American Insurance Companies and the famous Carlisle tables.
Section eleventh furnishes a synopsis of the ages of living population,
while in the final section, the twelfth, Dr. Billings gives his conclusions
and recommendations. Attention is called to the fact that, as the
country becomes more thickly settled, there is an increase of the pollu-
tion of soil and water, and a multiplication of the possible channels of
communicating the contagion of specific diseases, and hence the impor-
tance of towns improving their water-supply and methods of disposal of
excreta. Dr. Billings strongly recommends a uniform system or r
t ration of deaths throughout the country, with an annual publication

284 REVIEWS.

of such data. He also makes valuable suggestions with respect to the
methods of collecting the vital statistics of the next census, which, if
carried out, will add greatly to the value of the data furnished by thi3
branch of the census. W. H. F.

A Guide to the Practical Examination of Urine. For the Use of
Physicians and Students. By James Tyson, M.D., Professor of Path-
ology and Morbid Anatomy in the University of Pennsylvania, etc. Sixth
edition, revised and corrected. With a colored plate and wood engravings.
Philadelphia : P. Blakiston, Son & Co., 1888.

In the latest edition of this well-known manual, the author has brought
it fully abreast of the times, and it is now, as before, facile prim
among books of its kind. Too much praise cannot be given for the
judicial calm exercised in advocating the use of well-tried and trust-
worthy methods for the detection of albumin, at a period when every day
brings a new one, only to occupy valuable time and then disappear.
The addition of the phenyl-hydrazin test for glucose is a valuable one.
Having used the test in the modification given by Dr. Tyson for two
years, we have found its simplicity and certainty all that can be desired.
In regard to tests for bile-coloring matter, we have found that Huppert's
test {Arch, der Heilkunde, 8, 351 and 476) reveals minimal quantities
after Gmelin's and Heller's have both failed. G. D.

The Principles of Theoretical Chemistry, with Special Reference
to the Constitution of Chemical Compounds. By Ira Rkmbkk,
Professor of Chemistry in the Johns Hopkins University. Third edition,
enlarged and thoroughly revised. 12mo. pp. 318. Philadelphia: Lea
Brothers & Co., 1887.

The author does not assume too much when he takes the popularity
of his book as an evidence of the growing appreciation for theoretical
chemistry. By this and other works of hi-. notably his Organic Chem-
istry, he has done much to inspire students with a desire to know more
of the philosophical principles of chemistry than ordinary text-books
afford. Besides many minor additions, the reader familiar with t la-
second edition notes entirely new chapters on chemical affinity and on
the connection between constitution and chemical conduct.

No part of the general subject is so important as valenoe. In order
to make the book fairly representative of the best thinking on pafcnot,
the old chapter with that heading lias been rewritten and amplified.
We know do book on the subject which in a brief compass gives a state-
ment of chemical principles so lucid and complete.

PROGRESS

MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

FRANCIS H. WILLIAMS. M.D.,

ASSISTANT PROFESSOR Or MATERIA MEDICA ANP THERAPEUTICS IN HARVARD IXIVFRSITT.

Methylal, a Hypnotic in Mental Disease.

This substance was first introduced by Personam (Progres M&licale, July
2, lv - -7). On animals it had both physiological, sleep-producing and

toxic effects, ending in coma and paralysis with acceleration of pulse and
respiration. Like paraldehyde and most hypnotics, it is eliminated by the
lungs; it controls convulsions and is antagonistic to strychnia. Mairet et
Oombemale found that gr. lxxv-5ij were necessary to produce sleep, and
that it was of value in chronic mental cases, but not in acute ; that the effect
was exhausted in six or eight days, but a few days' rest made it active again.
It is relatively all the more valuable because in mental cases few hypnotics
are to be depended upon ; chloral, especially, in these observers' experience, is
often disappointing.

The dose is given in sweetened water at bedtime. The analysis of cases
is minute and the number of groups large, but it suffices to say that the results
in general were good, except in acute mania. Special advantages are its
solubility, pleasant taste and innocuousness. The authors consider it "justly
superior to chloral, urethan and opium preparations." — L'encephal, 1888,

: p. 281.

SlJLPHONAL AS A HYPNOTIC.

The agreement among observers as to the unqualified merit of sulphonal is
certainly remarkable. In addition to the original articles referred to in the
July number of this journal, accounts of its use may be found as follows:
Langgard u. Rabow, Thrr. Monatihefte, May, 1888 ; Salgo, Wiener med. Wochen-
schrift, No. 20; Rosin, Berlin. Llin. Wochervchrifl, No. 18; (Estreicher. Ibid.,-
Cramer, Miineh. med. Wochensrhri/f, Juno 12, 1888, p. 395; Schwalbe,
Deutsche med. Wochenschrift, June 21, 1888, p. 499; Rosenbach, Berlin, klin^
Wochenschrift, June 11, p. 481.

(Estreicher finds it somewhat slower in action than the other hypnotics

286 PROGRESS OF MEDICAL SCIENCE.

and advises its administration several hours before bedtime — nevertheless,
he finds it very reliable, and recommends it especially for mental cases.
Cramer's experiments wholly lie with this class. In 407 trials on 92 mental
patients he had positive success in 92.6 per cent., the administration being
followed by sleep of five or more hours, commencing for the most part in half
an hour. He saw no bad results, though in one case 3J in six days, and in
two others gr. xlv daily for two months were given.

Sohwalbe's paper is the most exhaustive, and his trials very carefully
conducted. Out of 50 patients, in 66 per cent, a prompt and satisfactory
action was obtained; in 24 per cent, the result was relatively poor, and in 10
per cent, negative. The patients had varied diseases, but analysis shows the
important (act that in 24 cases of purely nervous insomnia success was com-
plete in 90.3 per cent. On the contrary, when the primary affection deter-
mined the sleeplessness, the test was satisfactory in only 44.4 per cent, of
cases. Schwalbe concludes from this, in agreement with Kast, the original
observer, that sulphonal is purely a hypnotic and not a narcotic ; that it has
the power to quiet the excited brain and restore the equilibrium, if disturbed
by a minor influence only (e.g., & slight amount of pain), but retains this
power only within narrow limits. Unlike morphine, it does not first diminish
pain before sleep, nor in cases of cough did it diminish the tendency thereto
during sleep. Schwalbe found it of no effect in cardiac dyspnoea, contrary to
the experience of Kast (amylen hydrate, on the other hand, Schwalbe found
to produce sleep in these cases, or at least an improvement in the dyspnoea).
In twe.ve per cent, of cases, slight ill-effects were produced, of which the most
constant were headache and vertigo, but nothing of importance. No serious
after-effect was observed. In children the success was especially well marked.
Schwalbe's dose wasgr. xv-3ss; in children, gr. iv.

Warming Medicines before Administration.

Lewin (Berliner klinische Wochemchrift) recommends the warming of medi-
cines before administering and of subcutanoeus solutions as well. The ab-
sorption, he points out, is much quicker and the dose necessarily smaller.

Salicylate of Bismuth.

This preparation is said to combine the astringent properties of bismuth and
the disinfecting worth of salicylate, and has been administered by Khkim;
//•/'. Kufh-rlr i'hnn le, ix. p. 90) to a great many children with digestive
disturbances. It proved itself a most excellent remedy in gastro-intestinal
catarrhs depending essentially upon abnormal fermentation, especially If
combined with lavage of stomach and intestines. It was given in the follow-
ing mixture:

Bismuthi salicylat .^j.

Glycerin

AquiB q. s. ut ft. ^iv.

One drachm every two hours, more or less according to age of child.
Taken as a powder it is apt to cause some gastric irritation; in one pet cent
of cases a slight salicylate eruption appeared. Bhring thinks the remedy

THERAPEUTICS. 287

oiiirlit to be of use in cystitis and ammoniacal urine, since the urine after
seventeen hours shows increased acidity and decomposes less readily.

ACETANILIDE — AnTIFEBRIXE.

These two substances are identical, but Squibb (Ephemeris, vol. iii. No. 3)
observes that the name antifebrine is controlled by patent, and consequently
the price is enhanced. Acetinilide costs only half as much as antifebrine and
one-eighth as much as antipyrine.

Saccharin.

According to the latest analysis, saccharin is a white powder, showing
under the microscope a crystalline form and soluble in eighty per cent,
alcohol or in hot water. It does not reduce Fehling's solution. It suffers no
change in the system, and its elimination by the urine commences in half an
hour (Dcuf. med. Z>it., February 23, 1888, p. 197). The substance was first
obtained in 1879 from coal-tar, and, on account of its intense sweetness (two
hundred and eighty times that of sugar — one to two grains sweeten a cup of
coffee), has come to be liberally used in manufactures — e. g., beer.

In medicine its chief uses have been in diabetes, in place of cane sugar and
as a corrigent. It has been looked upon as an indifferent substance in its
effect on the system. Thus, Prop. Mosso gave it in large quantities to
animals without damaging results, and gr. lxxv in men produced no bad
effects. Salkowski (Virchow's Archiv, cv. p. 46) confirmed its innocuousness.
Stapelmax, employing it on eleven patients, in doses of grs. 1 to grs. lxxv,
found it harmless in nine, while in two others it caused severe gastric dis-
turbance. Prof. Leydex, on the other hand, saw no ill results in a pretty
extensive use of it in small doses of grs. ijss to grs. iij. Recently Dr. Worms,
in a paper read before the Paris Academy of Medicine (La Tribune Med.,
May 13, 1888, p. 234), has reviewed the question and presented it in not quite
so favorable a light. Used by five diabetics in the dose of gr. ss twice a day,
it could not be borne in three of the cases longer than eight or ten days, but
then caused loss of appetite, nausea, severe gastric pains and a sweet taste in
the mouth. The reviewer emphasizes the need of further physiological study
of saccharin, and looks upon the previous clean record as largely in the
nature of certificates for the benefit of manufacturing chemists!

Saccharin has antiseptic properties, and liosso noticed the fact that the
urine of animals taking it kept longer. Little (Dublin Journal of Medical
tee, June, 1888, p. 493) has reported his use of it in ammoniacal urine
dependent on paralysis of the bladder, on stricture or on prostatic disease. The
results were highly satisfactory in a series of half a dozen cases. In one case
of multiple calculi, in an old lady in which operation was refused, the urine,
which had been intolerably putrid for three months, became non-ammoniacal
and sweet in three or four days, and continued so. Little has not found it
upsetting to the stomach ; in fact, he emphasizes this point of advantage over
other drugs given to improve the urine.

Eichhorst (quoted in jfjwcft. med, Wochsft., July 10, p. 478) in the treat-
ment of diabetes, finds saccharin of much worth, but warns against its use in

288 PROGRESS OF MEDICAL SCIENCE.

too large quantities, as it easily produces an unpleasant after-taste, nausea and
disgust for the medicine.

Dose of Aconitia— a Warning.
The Pharmaceutical Society of Paris (Presse med. Beige, April 22, 1888, p.
135) sounds a note of caution in the use of aconitia. Numerous accidents from
it were reported, though no notice of them had appeared in public print, and
the alkaloid was declared perhaps the most violent poison known. Gr. ^-^
(the usual dose of Duquesnel's aconitia) had produced in an adult dangerous
symptoms. Granules of this strength were condemned, and it was recom-
mended to dispense those of a strength ofgr. ^J^! in order rightly to propor-
tion the dose. Digitalin was also declared powerful for evil and its dose too
large.

Cocaine in general Anesthesia.
Holger-Rordam, of Copenhagen (Schmidt's Jahrb., 1888, ii. p. 35), uses
gr. j of cocaine, injected five minutes before commencing amesthesia with*
chloroform, and claims for it that narcosis results much quicker, that the
stage of excitement is wanting and that less chloroform is needed. No bad
effects were observed either during or after the anaesthetic.

OXYCYANIDE OF MERCURY THE BEST OF ANTISEPTICS.

Compared with corrosive chloride ( Comptcs rend. d. Soc. d. Biol., July 6,
1888, p. 585):

1. Its solution has a slightly alkaline reaction and precipitates albumin
only slightly.

2. It is less irritant than solutions of sublimate.

3. There is less absorption by tissues than in case of sublimate.

4. Solution i^th does not attack, except slightly, the materials used in
surgical instruments.

5. Tested by its power of keeping soup, the antiseptic power showed itself
six times greater than that of the bichloride.

6. Tested by the power to destroy the micrococcus pyogenes aureus, the
advantage was slightly in favor of bichloride, x^vth t0 Tata1*1.

7. Employed on suppurating surfaces or to render a raucous surface anti-
septic, it furnishes much better results because of the tolerance by tissues and
of feeble absorption.

The cyanide of mercury has about the same properties, but the oxycyanide
is more powerful against the micrococcus pyogenes aureus.

Creolin as Antiseptic and Antiparasitic for the Intesti

1 1 1 i.i.f.r, of Breslau, writing in the DeuU-h. med. Woehauekrift, July 5, 1888,
speaks in the most unqualified terms of praise in regard to creolin. In unino-
niacal urine, washing out the bladder with jsVath has given good results. Its
propiTtn s as an antizymotic, its harmlessness and its non-irritating nature com-
bine to make it the best of antiseptics for the gastro-intestinal tract. Hiller
has accordingly used it in wry many cases of catarrh, flatulence, meteorism,

THERAPEUTICS. 289

with gratifying success. The dose has been gr. v-xv, usually t. i. d., an
hour after meals, in thick gelatin capsules (thin capsules are acted upon by
the creolin). The taste is tarry and disagreeable. In no case has he observed
bad effects, and he has given as much as gr. cl in four days. A slight sensation
of warmth and some taste in mouth after half an hour were the only sensa-
tions observed. Foulness of feces is corrected, diarrhoea diminishes and dis-
tention of abdomen disappears. Twice it was efficient as a vermifuge. Creolin
is not soluble in water nor in gastro-intestinal juices; but of the emulsion
•which is formed Hiller believes that absorption would be slight.

[Creolin is a coal tar product. The latest analysis [Deutsche med. Zeitsc/iri/t,
May 24, 1888, p. 516) makes it a compound mixture of carbolate of sodium,
a resin soap, a fat soap and a hydrate of sodium. — Ed.]

Antiseptic Action of Chloroform Water.

This useful property of chloroform is well illustrated in the Deutsche med.
' Wockensrhri/t, Heft 19. Prof. Salkowski calls attention to the powerful
antiseptic properties of chloroform water, which he extols in no mistakable
terms. Having used it for years to prevent the decomposition of urine,
special experiments have shown him that, if the chloroform be kept from
evaporating, it stops all fermentative processes conditioned upon the vital
activity of microorganisms; thus, milk keeps for months its original neutral
and alkaline reaction. Solutions of cane and grape sugars, mixed with yeast,
do not ferment. Albuminous solutions, meat-juice keep perfectly sterile ;
while ordinary solutions, used for purposes of control, showed bacteria in
two days. It is, too, a disinfectant as well as an antiseptic. Very stinking
meat juice, shaken with chloroform water, was sterile after one hour's stand-
ing. Anthrax bacilli were innocuous after twenty-four hours' contact, and a
culture of cholera comma bacillus was made inert in a minute.

From this experimental evidence Salkowski draws the following practical
hints and urges experimental trial of chloroform water:

1. Chloroform water in the laboratory is a decidedly superior agent to add
to all ferment solutions, albuminous fluids, extracts, etc. ; it is far ahead of
any other antiseptic. Here its volatility is of great advantage, permitting its
removal by heat or air current when necessary. To preserve urine unchanged
it is of great value. In urine already alkaline chloroform will not act on the
soluble ferment present.

2. For the preservation of smaller anatomical preparations; the only draw-
back is its taking up the blood coloring matter, a difficulty which further
experience may obviate.

3. In therapeutics as a solvent for alkaloids in solutions; subcutaneous
injection, for the irritating effects of the chloroform are slight. With so few
antiseptics of disinfection of the alimentary canal among our resources, this
adaptation of it should be borne in mind.

Animals bear very large quantities (a dog got for four days in succession
Svij in his food, without any effect). In cholera it should certainly be tried.
Exceptionally in emergencies it might be used as an external antiseptic,
though inferior to others. Its easy preparation (n\,lxxv -f (75!), shaken in a
quart of water) is a recommendation.

290 PROGRESS OF MEDICAL SCIENCE.

[This proportion of chloroform is rather large, as about 1 part of chloroform
to 200 of water is as much as will dissolve. — Ed.]

A similar laudatory estimate of the value of chloroform in pharmacy for
the preservation of extracts, making solutions of drugs, etc., may be found in
the American Journal of Pharmacy, May, 1888, p. 248.

Unna {Monatih.f. prakt. Dermat., 1888, Heft 9), on the recommendation
of Hager, has used aqua chloroformi as a vehicle for subcutaneous solutions.
He finds it to serve its purpose in preserving the solutions, while the chloro-
form, though it causes a slight burning sensation in the morphia solution, is
of advantage through its anaesthetic properties in «uch solutions as that of
ergotin and in Fowler's. For these he recommends it especially.

Internal Antisepsis.
Baginsky (Deut. med. Woch., May 17, 1888), in an article on fermentative
processes in the alimentary canal of children, points out that the question is
by no means so simple as the mere presence of bacteria and getting rid of
them ; e. g., he has shown that the bacterium lactis (for which he substitutes
the name bacterium aceticum) normally present in the intestine destroys a
pathological bacterium found in green diarrhoea — in other words that '' a
powerful antibacterial treatment, even if it were successful in the destruction of
germs, as it is not, can under circumstances be a damage, because it interferes
in the independent extermination fight of different forms of bacteria."

Antiseptic Treatment of Typhoid.

Legroux (Le Bull. Med., June 17, p. 805) has used the following treatment
in a large series of cases and believes in it. To all cases a good dose of
calomel is first given, then if diarrhoea is prominent —

Naphthol )

Bismuth } aa gr. xl.

Make ten powders and give one every hour in capsule or suspended in milk.
If less diarrhoea, naphthol alone in same dose.
If tendency to constipation —

Naphthol gr. xl.

Magnes. salicylat gr. xl.

Ten powders as before.

Legroux finds in this treatment numerous advantages, both local and gen-
eral, as, e. >/., disinfection of stools, diminution of meteorism and believes it
aflecta favorably the course of the disease.

Action of Carlsbad Water on the Gastric Functions.

Sandberg and Ewald {Onlrnlblalt f. d. med. Wistensch., Nos. 16 and 18,
1888) have determined by a series of experiment! the effects of Carlsbad water
on the functions of the stomach.

For this purpose ten persons (of whom but three goffered from indigestion)
were subjected to treatment, which consisted in administering water from the

THERAPEUTICS. 291

Miihlbrunn spring, in quantities varying from a half pint to a pint and a
half and at temperatures ranging between 68° and 122° F., for from thirty
to thirty-six 'lays. The effects were determined by examining the contents of
the stomach removed by the stomach tube.

The results obtained, as will be seen, deviate very materially from those of
Jaworski, who found that the continued use of Carlsbad water caused a dimi-
nution of both the hydrochloric acid and the pepsin of the gastric juice, and
that finally the sensibility of the gastric mucous membrane became so far
diminished that even the introduction of food was frequently insufficient to
stimulate it to secretion.

A nummary of their results is as follows:

1 . i arlsbad water is a powerful gastric stimulant, so much so that half an
hour after its ingestion it is often possible to demonstrate the presence of
hydrochloric acid in the stomach contents.

2. After a four to five weeks' course of treatment no diminution in the
secretion of pepsin could be noticed.

S. The same is true of the rennet (milk-curdling) ferment.

4. In those cases in which, before treatment, the acidity was rather below
normal, the secretion of pepsin and of rennet was increased.

5. Carlsbad water stimulates gastric activity more powerfully than common
water of the same temperature.

6. Absorption occurs very quickly ; a half pint disappearing in fifteen to
forty-five minutes.

7. Absorption takes place more rapidly at temperatures of from 122° to 131°
F., than at lower ones of 68° to 104° F.

Caffeine Subcutaneously as a Cardiac Tonic.

II f r chard [Lc Bull. M&L, May 27, p. 705) gives the preference to caffeine
over any cardiac stimulant for the relief of heart weakness dependent on any
peripheral condition as — e.g., pneumonia. It has these advantages: that its
action is rapid, its elimination quick and that it is harmless. Digitalis (so
commonly used in America) is too slow, requiring three to four days for its
action. Caffeine acts in three ways : 1. General tonic ; 2. Cardiac tonic ; 3.
Diuretic. Heuchard uses it also in all adynamic states, it displacing ether in
his estimation.

Formula:

Sod. benzoat 3

Caffeine . . 2

Aq. destill. , 6

Give four to six syringefuls.

General Antidote for any Poison of Unknown Xaturb.

Magnes. ust. ")

( arbon. lig. . Equal parts with sufficient water.

Ferri. oxid. hydrat. j

— J 'harm. Rundschau.

292 PROGRESS OF MEDI'^ L SCIENCE.

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLiJEt, M.D., F.R.C.P. Lond.,

professor or clinical medic: ne in the university of pennsylvania.
Assisted by

J. P. Crozer Griffith, M.D., Walter Mendelson, M.D.,

ASSISTANT PHYSICIAN TO THE HOSPITAL OF THE PHYSICIAN TO THE ROOSEVELT HOSPITAL, OUT-

UNIVERSITY OF PENNSYLVANIA. DOOR DEPARTMENT, NEW YORK.

The Treatment of Typhoid Fever by Carbolic Acid.

Sidney Gramshaw {Lancet, 1888, i. 1243) reports his results with this
drug, used after Rothe's method, in one hundred and sixteen cases of typhoid
fever during the last seven years. The general management of the cases con-
sisted in the administration principally of a diet of milk and of a mixture
containing one and a half minims of pure carbolic acid and two minims of
tincture of iodine every four hours for the first fortnight, or until the urgent
symptoms yielded, then three times a day. The good effect is manifest almost
immediately, and it sometimes happens that a case is cut short almost as
quickly as is acute rheumatism by salicylic acid. Brandy and champagne are
given if needed. Beef-tea is avoided during the fever, as it is apt to produce
diarrhoea. The carbolic acid can be perceived in the breath and perspiration,
but rarely causes carboluria. If it induces vomiting, the dose should be di-
minished. Only one of the one hundred and sixteen cases died, and this
from pneumonia after the fever had disappeared. Though very numerous
cases recover absolutely without treatment, the author thinks it certainly
safer and more advisable to use such means as will at once put the patient on
the road to convalescence; and his cases show that carbolic acid will do this.

Peripheral Neuritis in Acute Rheumatism and the Relation of
Muscular Atrophy to Affections of the Joints.

Judson S. BuRY {Manchester Medical Chronicle, 1888, viii. 182) devotes his
attention to the consideration of certain phenomena frequently mot with
during or subsequently to an attack of acute articular rheumatism, but which
have received but little attention from writers; namely, the paralysis and
■trophy of muscles, mnwtihoilll in the course of the peripheral nerves, and
enlargement of the ends of the bones. After reviewing the literature of the
subject, and reporting eleven cases illustrated by woodcuts, the author draws
the following conclusions :

1. That in articular rheumatism we constantly meet with the muscular
atrophy and paresis common to other joint affections. Their sudden onset
would Indicate that they are due to a reflex irritation conducted along the
sensory nerves from the joint to the cord, and which appears to inhibit the
functional activity of the motor cells in the anterior horns. Their duration and
progressive character suggest organic changes, either central or peripheral.
The presence of increased reflexes, sometimes of contractures, and the fact

*C»DICINE. 293

that rarely a lateral sclerosis may start from an arthritic attack indicate that
the pyramidal tract or its connections may be involved as well as the motor
cells.

2. That wasting of the interosseous muscles of the hand is one of the com-
monest phenomena of acute, subacute ( chronic rheumatism ; and that
while some cases may be due to the reflex irritation described, in a large
number the atrophy is the result of an ulnar neuritis ; as is proved by the
distribution of the wasting in the hand.

3. That although the ulnar nerve is by far the commonest to be affected,
other nerves of the brachial plexus, and branches of the lumbar and sacral
plexuses are frequently attacked.

4. These peripheral nerve symptoms may occur in a limb quite free from
joint irritation. If then there are found paralysis, atrophy or anaesthesia in
the course of the ulnar nerve during an attack of rheumatism, or after the
pyrexia has subsided, in a limb where the joints are free, it would appear
very probable that there existed a neuritis set up by the rheumatic poison.
This is rendered still more likely by the evidence found by Pitres and Vail-
lard of the very common occurrence in phthisis, tabes and typhoid fever of
neuritis in regions of the body in which during life symptoms of such neuritis
were but slight.

Cascara Sagrada in* Rheumatism.

Goodwin {New York Med. Journ., 1888, xlvii. 629) calls attention to what
he claims is the almost specific action of this substance in certain forms of
rheumatism. His first experience was in his own person when suffering from
acute rheumatism, when he found that ten drops of the fluid extract taken
three times a day as a laxative removed the rheumatic pains completely in a
short time. Since this event he has used the drug in about thirty cases and
has obtained the most satisfactory results, except in a few instances in which
there was a syphilitic taint. The initial dose employed was fifteen minims
thrice daily, and it was rarely necessary to increase this amount. The bene-
ficial effects usually occurred within twenty-four hours. In a few cases it has
opened the bowels too freely. The author suggests that if this happens a
preparation of iron should be administered separately at the same time.

Birth Palsies.

Injuries to the nervous system during birth, says Gowers (Lancet, 1888, i.
709, 759), may occur to the peripheral nerves or to the brain ; and one case is
reported of a spinal birth palsy. The peripheral form is usually seen in the
facial nerve or in the nerves of the arm. The former is due to the pressure
of forceps, the latter either to the same pressure in front of the trapezius, to
that of a traction hook above the shoulder in breech presentations, or to a
fracture of the humerus. But the commonest and most important form is the
cerebral birth palsy. That this is due to an injury received during birth, is
shown by the fact that almost all cases have been instances of difficult partu-
rition, often terminated by the forceps. Of twenty-six cases of this affection
of which the author has notes, the child was a first-born in sixteen, and in
six of the others the head was delivered last. The external signs of severe

294 PROGRESS OF MEDICAL SCIENCE.

pressure from the forceps are often to be seen, and sometimes convulsions in
the first few days of life indicate the morbid state of the brain. Further au-
topsies show the lesions of cerebral hemorrhage, usually situated at the con-
vexity of the brain.

Among the symptoms may be often noted a blood tumor of the scalp. There
may be apparent death, or general convulsions and rigidity. In slighter
Cttefl it is only when the child should begin to walk and talk that a rigidity
of the legs is discovered and usually spasmodic, athetoid or choreiform move-
ments of the arms, with a degree of incoordination. Inability to support the
head, curvature of the spine, strabismus and difficulty in articulation and swal-
lowing are sometimes present, and mental defect is common. The disorder
is usually bilateral, but sometimes limited chiefly to one arm. Very com-
monly the arms escape, and there is adductor spasm of the legs with cross-
legged progression. Recurring convulsions are sometimes seen, and may
continue as a form of epilepsy. The preponderance of the affection of the
legs is due to the fact that their centre is situated nearer the middle line and
the point of greatest compression then is the arm centre. The difficulty in
swallowing, and the retraction of the head are probably caused by hemor-
rhage in the region of the medulla. It is likely that many cases of epilepsy
and of mental defect are due to slight damage to the brain during birth.

The diagnosis of the malady rarely presents much difficulty. The most
important distinctions from other cerebral diseases are that there is no history
of a definite onset at any time after birth, and that the condition is not pro-
gressive. These two features distinguish it from tumor of the pons producing
bilateral weakness and spasm. Accidental hemiplegia occurring during
infancy may resemble one-sided birth palsy, but there is usually a distinct
history of acute symptoms at the onset. Moreover, even in the apparently
unilateral birth palsy, there is almost invariably some slight disturbance of
the same kind as that on the affected side. In the cases in which the legs
suffer much more than the arms, the diagnosis from cases of spinal spastic
paralysis is difficult. Still in the birth palsy traces of the disorder will be found
in the parts which appear at first sight to be free. The movements of the
hands are distinctly awkward, and differ from those of a healthy child. Then,
too, the case is probably one of birth palsy if there is no history of definite
onset, and the child has never been able to walk ; since chronic disease of the
spinal cord is almost unknown in childhood. When the weakness of the
legs is slight, the gait somewhat awkward, the muscles large and firm, and
the calf-muscles somewhat contracted, the case may be mistaken for one of
pseudo-hypertrophic muscular paralysis. It is, however, distinguished from
the latter by the absence of the characteristic condition of the muscles around
the shoulder, the fact that the contraction can be overcome, and the presence
of exaggerated reflexes and of reflex spasm 00 cutaneous stimulation.

As regards the prognosis, the tendency is toward slow improvement, particu-
larly slow in the first half of childhood. In almost all cases in which there
h Dot actual idiocy, the patient ultimately learns to control the mnsdea and to
walk, though in severe cases the gait almost always preserves more or
peculiarity. The hands also become steadier in time. No opinion can DC
given as to the mental condition until the second year of life is passed, when
the prognosis will be guided by the amount of defect discovered.

MEDICINE. 295

Treatment consists in training the motor powers by rhythmical gymnastic
exercises, in checking any tendency to epileptiform seizures and in employing
instrumental support if necessary. Operation for talipes is never justified, as
there is no permanent shortening of the muscle. Electricity is useless.

Muscular Atrophies and Hypertrophies.

Lax dox Carter Gray (iftp York Med. Journ., 1888, xlvii. 533) says that
disease of any part of the neuro-muscular apparatus — i. e., the muscles, the
motor nerves and the ganglion cells of the anterior column of the gray
matter, is apt to extend to the two other parts or to be associated with them.
This apparatus begins with the centres in the third ventricle and terminates
with the motor end-plates in the muscle. There are reasons to believe that
the ganglion cells of the anterior columns are of two kinds, determining
either motor paralysis or wasting of the muscular fibre as the first and pre-
dominant symptom. Nevertheless, in every case of disease of this region of
the cord, there are, sooner or later, both muscular atrophy and motor paralysis.
Disease of any part of the neuro-muscular apparatus produces the three
symptoms: 1, motor paralysis; 2, muscular atrophy; 3, electrical changes,
brought about by degeneration of nerve and muscle. It is easy to under-
stand, then, why there is so much dispute as to which part of the apparatus
is affected when these three symptoms are present. As the nervous system
can only express itself through the muscles, it is the muscles that we are to
study in all diseases of the neuro-muscular apparatus.

The disorders of this apparatus are known as : 1. Myelitis of the anterior
cornua. 2. Glosso labio laryngeal paralysis or bulbar paralysis. 3. Pro-
gressive ophthalmoplegia. 4. Muscular pseudo-hypertrophy. 5. Progressive
muscular atrophy. The first three are due to lesions of the anterior column,
consisting principally of destruction of the ganglion cells, with subsequent
atrophy of the muscles and nerves ; the fourth is of muscular origin ; the fifth
may be due to spinal or to muscular lesions, or to both. 1. Myelitis of the
anterior horns is a lesion in the anterior gray matter of the cord. It produces
an acute, subacute or chronic paralysis of the extremities, followed by atrophy
and altered electrical reactions of the muscles. In children it is usually con-
fined to one limb; in adults it is generally in the form of paraplegia. It is
-: common in the first three years of life and between the ages of eighteen
and forty. 2. Glosso-labio-laryngeal paralysis is due to implication of the
nuclei of the hypoglossal, facial and spinal accessory nerves in the medulla.
It is a paralysis usually preceded by atrophy affecting, in order, the tongue,
the lips and lower part of the face and finally the larynx, pharynx, oesopha-
gus and heart. There is difficulty in the pronunciation of the tongue and
lip sounds. 3. Progressive ophthalmoplegia is caused by an affection of the
nuclei of the ocular nerves in the floor of the aqueduct of Sylvius and the
third ventricle. The muscles involved are sometimes the internal (sphincter
of the pupil and tensor of the choroid), sometimes the external and some-
times partially both. 4. Muscular pseudo-hypertrophy is a disease of early
childhood, beginning with falls and increasing weakness. There is a deposit
of fat around the muscular fibres, especially of the lower extremities. The
arms and shoulders are usually affected simultaneously, and the contrast be-

296 PROGRESS OF MEDICAL SCIENCE.

tween the atrophy of the parts and the apparent hypertrophy of the legs is
very striking.

I'ruijressive muscular atrophy is a disease about which there has been much
confusion, increased by the effort to form many different "types." We may
accept four types : a. The hand type, which begins with the muscles of the
thumb and fingers, producing the "ape hand" or the "claw hand," often
after a long time extends up the arm involving certain muscles in a regular
order and sooner or later attacks the trunk and possibly the nuclei in the
medulla, b. The juvenile type (Erb), in which the onset is almost always in
the muscles of the shoulder and upper arm, less often in those of the pelvis
and lower extremities, c. The infantile facial type (Landouzy and Dejerine),
which generally begins with an atrophy of the muscles of expression; with
the lips and eyes protruding, the brow like ivory, the motions of the lips
incomplete. When the face is wasted, the muscles of the shoulder and arm
are next involved, certain of them usually remaining intact, d. The peroneal
type (Charcot, Marie and Tooth), in which the muscles of the leg are first
attacked, then those of the hand and those of the forearm some years later.
The author gives a table stating exactly which muscles are diseased in each
type. The course of progressive muscular atrophy is gradual and the dura-
tion from five to thirty years. The paralysis is usually proportionate to the
atrophy. Sometimes pseudo-hypertrophy is conjoined with the muscular
atrophy. It would seem that most cases are of central origin, but a few are
clearly muscular.

As regards diagnosis, the presence of the three symptoms alluded to is ab-
solute proof of the existence of disease of the neuro-muscular apparatus. The
various forms are then to be distinguished from one another. When the
lesion is in the anterior columns, there are the symptoms peculiar to one of
the three diseases first described. The diagnosis of disease of the muscles
alone can only be positively made in muscular pseudo hypertrophy and in
the infantile facial type of progressive muscular atrophy. It has been claimed,
but it is not certain, that the " hand type" is always of central origin, or that
the "juvenile type" is uniform and purely muscular. Fibrillary contractions
and the reaction of degeneration occur in both central and peripheral forms.
Other diseases of the spinal cord and its membranes might extend into the
anterior horn and are to be distinguished from these under discussion by the
presence of their characteristic symptoms, as well as of marked sensory, ves-
ical and rectal disturbances. Such diseases are spinal hemorrhage, trans-
verse myelitis, syringo-myelitis and locomotor ataxia. Neuritis is distin-
guished by the presence of pain, oedema and hot, glossy skin; and multiple
neuritis by pain and steady progress of the bilateral paralysis aud atrophy
within | week or two, while the pain persists. Lead paralysis, meningitis
and atrophy from joint disease should be easily differentiated.

The ni"st frequent Sawei of the neuro-muscular diseases are infection,
heredity) muscular strain, trauma, acute diseases, exposure to continuous cold
or warm weather. Heredity is usually found in the infantile facial and
plays an important rols in all forms. Progressive muscular atrophy often
follows the acute diseases.

The prorjnosti varies. There is always an incurable residue in myelitis of
the anterior horn, bulbar palsy is always fatal and progressive ophthalmo-

MEDICINE. 297

_-ia usually so. Muscular pseudo-hypertrophy is incurable. Progressive
muscular atrophy usually runs a fatal course, but it is possible that the purely
muscular forms may be amenable to treatment.

/tent. — Rest, sometimes in bed, is of prime importance in every case of
muscle or nerve degeneration. The faradic, galvanic and, in cases of great
atrophy, the static electrical currents are to be applied to the spinal cord, the
motor nerves and the muscles themselves. Massage, used gently and not long
at a time, is sometimes useful, but may prove harmful. Drugs are of little use
except in the acute or subacute form of myelitis of the anterior horn and in
progressive ophthalmoplegia. Iodide of potash, ergot and strychnia may be
employed, but the author has never seen any tangible results from them.

Pleurisy as a Predisposing Cause of Phthisis Pulmonalis.

Wk-tbrook LV. Y. Med. Journ., 1888, xlvii. 617) says that, admitting the
tubercle bacillus as the undoubted exciting cause of phthisis, the question
arises regarding the existence of local or general predisposing pathological
conditions. Pleurisy would seem to be capable of producing a vulnerability
of the lung tissue, though in some instances it is probably merely an indica-
tion of constitutional weakness. Pleurisy is, at any rate, often observed as an
antecedent of phthisis, but the exact relation of the two has been much dis-
cussed. These cases may be divided into five classes :

1. Those in which a pleurisy with effusion occurring in a person with good
health is immediately followed by rapidly progressing pulmonary tuberculosis.
The pleural inflammation in these cases is undoubtedly of tubercular origin.

2. Cases of sero-fibrinous pleurisy, followed by a slow development of
chronic interstitial pneumonia. This pulmonary inflammation may be tuber-
cular in its origin, but the final development of distinct tuberculosis is at any
rate to be looked for.

3. Cases of sero-fibrinous pleurisy ending in recovery, but followed after
some months by the development of tuberculosis at one or both apices. These
are usually observed in persona constitutionally weak or whose health has
l»etn impaired. That the pleurisy was itself tubercular is possible, but
rendered improbable by its occurrence in the lower part of the chest, while
the tuberculosis which subsequently develops is

4. Cases occurring in middle or advanced life, in which a sero-fibrinous
pleurisy has become chronic, with deposits of false membrane, through
neirlect or failure to recognize the disease. Many of these finally develop
tuberculosis putmonum, but the interval is so great that the pleurisy cannot
but be regarded as primary and simple in its character.

5. Cases in which an empyema antedates the tuberculosis.

The author reports numerous instances illustrative of these classes and
draws the following conclusions :

'/. Sero-fibrinous pleurisies, apparently of simple origin and terminating
in complete recovery, may be followed, after a lapse of a few months, by
the development of phthisis pulmonalis.

b. In all probability the pleurisy in these cases acts as the predisposing
cause of the tuberculosis.

VOL. 96, SO. 3.— SEPTEMBER, 1888. 20

298 PROGRESS OF MEDICAL SCIENCE.

c. Primary serofibrinous pleurisy may result in fibroid phthisis with the
subsequent occurrence of tuberculosis pulmonum.

d. Fluid effusions remaining in the chest for a long time may, finally,
so interfere with the nutrition of the lungs or of the body at large as to
render it liable to general or local tubercular infection.

e. No case of pleurisy should, therefore, be neglected, but great care
should be taken that after apparent recovery the health is completely
restored. For at least a year the physician should keep a watch over the
patient and should order prolonged rest from business, change of climate,
etc. In patients who have reached middle life and whose costal cartilages
have begun to lose their elasticity, effusions should not be allowed to
remain in the chest more than two or three weeks and should be aspirated
at short intervals, if the fluid reaccumulates. If dulness and feeble respi-
ratory murmur continue after the fluid is absorbed, tonics and alteratives
should be persevered with for a long time. The regular employment of
gymnastic exercises and the inhalation of compressed air are great aids in
reexpanding the chest.

Cardiac Degeneration from the Pressure of Abdominal Tumors.

Bedford Fen wick {Lancet, 1888, i. 1015, 1067) enumerates the various
causes of degeneration of the heart muscle and says that no attention has been
drawn to the fact that the pressure of abdominal tumors may produce the
same effect. He reports twenty-two cases, chiefly of ovarian cystic diseases,
in most of which sudden death occurred, and in which the muscular fibres
were found to have undergone fatty degeneration. He concludes: 1, that
the sudden death which occurs in cases of ovarian cystic disease is often, if
not always, caused by fatty degeneration of the heart. 2. The long- con-
tinued upward pressure of intra-abdominal tumors is almost certainly a cause
of fatty infiltration and degeneration of the heart muscle. 3. The cystic
forms of tumor are those which most commonly exercise this morbid change;
perhaps, because they can exercise a greater pressure on the thoracic cavity,
for a longer time without killing the patient, than a solid tumor could do.
Pregnancy, it is true, is a kind of cystic growth ; but it does not produce this
change in the heart muscle, because it exerts considerable pressure for but a
very short time. Then, too, by a provision of nature, the heart hypertrophies
to meet the dangerous results of pressure thrown upon it by the pregnant
uterus.

The diagnosis of this condition of the heart is difficult, but is based upon
the pathological conditions present. 1. The heart's impulse is very feeble
and diffused, the sounds dull, especially over the right ventriele, and the
first sound, perhaps. Inaudible. 2. The radial pulse is feeble, small and
compressible. Its rate may he slow or rapid and irregular, but in either case
a very important symptom is that on the slightest exertion there is an
unuMial though temporary aceel. ration of the pulse. 3. There is a tendency
to local aiieiuias and loeal congestions, pallor of the skin, faintness and even
syncope, a constant inclination to yawn or sigh and. possibly, a marked con-
dition of dyspnoea. The diagnosis is aided if the age of the patient is over
forty, if she has wasted and has been compelled to lead a sedentary life and
it' the pressure has been kept up for over nine months.

MEDICINE. 299

Treatment should be directed toward improving the nutrition of the cardiac
muscle, while paying regard to the general health. Regular exercise, even a
little at a time, is all-important, and in view of the dangers to the heart, the
early removal of the tumor should be advocated, or, if this is not practicable,
tapping should be resorted to.

Hypodermatic Use of Nitroglycerin- in Heart Failure.

Fcssell {Med. and Surg. Report, 1888, lviii. 695) reports three cases of
heart failure in all of which death seemed imminent. The first patient
was a case of mitral disease, subject at times to the usual symptoms of general
venous congestion. She had been taking nitroglycerin by the mouth,
and had been feeling unusually well, when she was suddenly seized in the
night with intense dyspnoea, and soon became unconscious, while the lungs
were filled with bubbling rales. Two drops of a one per cent, solution
of nitroglycerin were administered hypodermatically, though the case was
considered hopeless. In twenty minutes the dose was repeated, and in the
course of an hour the patient could talk and lie down without trouble, and
the rales had almost completely disappeared from the lungs.

A second case was one of syncope and sudden heart failure in the course of
typhoid fever. The face was cyanosed, and the pulse irregular and so rapid
that it could not be counted. The drug in this instance had an equally good
effect. The third patient, one suffering from mitral disease, was relieved
from suddenly developing symptoms of extreme cardiac insufficiency by two
drops of a solution of the drug, followed by one drop more in half an hour.

The author highly recommends this plan of treatment on account of its
superiority to the hypodermatic use of whiskey or digitalis, both in certainty
and rapidity of action.

Brachycardia.

In a long article on brachycardia, or retardation of the pulse, Grob [Deutsch.
Arch. f. klin. Med., 1888, xlii. 574) reports a number of cases from his own
experience, and collects others from the literature, making 140 in all, of
which 131 were males. He divides the subject into physiological, idiopathic
and symptomatic brachycardia, and reports instances of each. The first
includes those cases in which there is slowness of the pulse without symptoms
in healthy individuals, or independently of the disease from which they may
be suffering. It is also seen in healthy women in the puerperal state, or
after abortions. Those fasting likewise exhibit the same phenomenon.

Idiopathic brachycardia is that which occurs with its attendant symptoms
as an independent disease, without any discoverable lesion of any organ of
the body. It sometimes follows the ingestion of indigestible articles of food,
depressing mental condition, extreme exhaustion, great pain, or nervous shock.
It may be considered a cardiac neurosis, and may be transitory or more
lasting. The third group, the symptomatic, is by far the largest, and includes
all those cases in which the temporary retardation of pulse is the result of some
other disease. The diseases causally related to the 122 cases of symptomatic
brachycardia which the author reports from his own experience and that of
others, are as follows : Articular rheumatism, 27 cases ; diseases of the circu-

300 PROGRESS OF y MEDICAL SCIENCE.

■

latory apparatus, 16 cases; diseases oLf fae digestive tract, 14 cases; diseases
of the central nervous organs and of &8 Qe peripheral nerves, 9 cases ; chronic
infectious and constitutional diseases, 9 cthiases . convalescence after acute febrile
disorders, 43 cases. The retardation of o t^e pU]se in rheumatism appear- to
be due to the influence of the poison upon «t t^e heart. In diseases of the heart
it may occur under a variety of conditions, one«-H Qf t^e m08t frequently reported
being fatty degeneration of the organ. Among n-<e„ervou8 affections which may
produce retardation of the pulse are both simple anu .^ tubercular meningitis,
as well as pachymeningitis hemorrhagica in some cases,es. the first stages of
apoplexia cerebri, syncope and apparent death, increased wo.^ntracranial pres-
sure, especially of the medulla oblongata, produced by turnout rs or in other
ways, occasionally injuries of the upper part of the spinal corund, diseases of
the peripheral nerves, as illustrated by some cases of sciatica, disei It^es of the
cardiac nerves themselves, exceptionally Basedow's disease instead of a: causing
the usual acceleration. ^yi-

Brachycardia in diseases of the digestive tract, produced by reflex ac action
through the vagus or splanchnic, is seen in indigestion, long-continuing cl ->n-
stipation and icterus. The author has also seen it in a case of carcinoma
oesophagi, one of carcinoma ventriculi, one of ulcus ventriculi and in two ""S.
cases of typhlitis. Chronic infectious and constitutional diseases producing
quite marked but temporary brachycardia, are represented in his experience
chiefly by cases of gonorrhoea and soft chancre, all of them complicated by
epididymitis or by bubo, and further by a case of anemia. In convalescence
from the acute febrile diseases it is seen especially after typhoid fever, but is
also reported after typhus, diphtheria, pneumonia, measles and scarlatina. It
is also to be remarked that in rare instances the pulse is retarded during the
fever, to reach its normal frequency during convalescence.

Certain symptoms not infrequently attend the retardation of pulse, among
which may be mentioned fainting, extreme oppression, epileptiform or apo-
plectiform attacks, vertigo and attacks of weakness.

A Case of Icterus Gravis ; Acute Cirrhosis of the Liver.

kxer (Deutsch. Archivf. klin. med., 1888, xlii.615) reports an interesting
case, in which, after a sudden onset with headache, vomiting and weakness
without known cause, icterus developed and was attended by bleeding from
the nose and gums, headache, extreme restlessness, eructations, bad taste in
the mouth, icteric urine, general pain and some tendency to stupor. The liver
was very tender to pressure and somewhat swollen. Later the stupor deepened,
the swelling of the liver grew less, the urine contained leuein and t\ rosin, the
temperature arose suddenly to over 104°, and the patient died with the symp-
toms of acute pulmonary oedema after an illness of twelve days. The ante
ihowed the liver to be of nearly normal size, and, for the most part, of an
ochre-yellow color. Under the microscope there were found the evidences
of an aeute inflammation of the connective tissue of the oriran, with com-
presuioD and atrophy of the liver cells, but without any signs of the primary
i-ration of the glandular structure of acute yellow atrophy.

SURGERY. 301

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

SfROEON TO THR PHILADELPHIA AND GERMAN HOSPITALS; CLINICAL PR0PRS8OR OP ORNITO-URINA RT
SUROERT IN THR UNIVIRSITT OP PENNSYLVANIA.

Iodoform Tamponade.

Dr. Emil, Sexger (Deutxeh. medirin. Woch., No. 24), in his Annual Retro-
spect of Surgery, says: The iodoform tamponade is to-day used in many
clinics, and is especially applicable to wounds, of the absolute sterility of
which the operator cannot be assured. At the time of operation the wound
is packed with iodoform gauze, the sutures are inserted, but not tied, and the
wound is dressed antiseptically ; if on withdrawing the tampon the wound
is found free from reaction, the surfaces are approximated and the sutures
knotted. Helferich groups the cases which especially indicate this method of
treatment under four heads. He urges its adoption in the surgical treatment
of: 1, tuberculosis ; 2, all septic wounds ; 3, bleeding; 4, diseases of the intes-
tinal or genital tract.

Skin Transplantation.

Thiersch presented to the Deutsch. Gesellschaft fur Chirurg. (Beilagc zum
OentrcUbhttfur Chirunjis, Xo. 24, 1888) two cases of extensive skin transplan-
tation. The first, suffering from a superficial carcinoma of the forehead, the
size of the palm and involving the bone, underwent an operation, by which
the whole diseased area was removed, including the pericranium and affected
bone. A small surface of dura mater was exposed near the root of the i
Since transplanted skin will not adhere to compact bone, the borders of the
opening were freshened by means of a hammer and chisel. The bleeding was
entirely checked by pressure and the wound covered in by long and moder-
ately broad flaps. In ten days it was entirely healed, except in a few spots
where the freshening of the bone was neglected. Three weeks later the
whole wound was granulating, the skin having disappeared, and three new
cancerous nodes were seen in the surrounding skin. The nodes were removed,
the granulations scraped, the whole surface was again covered with trans-
planted skin, and permanent healing quickly followed.

The second patient was suffering from a malignant ulceration of the left
side of the face. The cheek and lower eyelid were mostly destroyed ; also tho
lateral surface of the nose, the inner commissure of the eyelids, and the inner
half of the upper eyelid ; the cavities of the mouth and nose were oth opened.
Extirpation of the diseased area, including the eyeball and affected bone
was performed. Since the transplantation of isolated pieces of skin upon
raw surfaces which communicate with mucous membrane cavities is not suc-
ul, the wound was closed by a flap, the size of the palm, taken from the
frontal and temporal regions, preserving in front of the ear a root about the

302 PROGRESS OF MEDICAL SCIENCE.

breadth of two fingers. The gap in the fronto-temporal region was completely
covered in by strips of skin. Both wounds were entirely healed in eight days.
In both cases sterilized salt solution (6 : 1000) and sterilized dressings were
used in the operation and after treatment. Thiersch prefers moist to dry
dressings.

The Prognosis of Cancerous Affections.

Fischer, in 1881 (Deutsch. Zcitsi-hrift fiir Chirurg., xiv. Bd.), published the
statistics of Professor Rose's cases of malignant disease operated on in the
Zurich Canton Hospital and in private practice from 1867 to 1878; in all, 298
cases. Leaving out the private cases, 42 in number, there were living at the
time Fischer's article appeared 98 patients.

In the interest of a more thorough knowledge as to the ultimate prognosis
of malignant diseases Meyer reports {Ibid., xxviii. Bd. 10, 2 Heft) the result
of his investigation into the subsequent history of these cases.

Of the 98 patients, definite knowledge could be obtained of 64. 22 are still
living and free from recidivity. 19 died from causes not connected with their
original disease ; of this number, 6 perished within three years of the opera-
tion, the remaining 13 at periods varying from 4 to 16 years.

Of the 22 patients still living, 11 suffered from carcinoma, 7 from sarcoma, 1
from melano-sarcoma, 1 from careinoma-sarcomatodes, 2 from cysto sarcoma.

In all these cases, the diagnosis had been confirmed by microscopical
examination.

Ohren (Archiv fur klinisch. Chirurg., xxxvii. Bd., Heft. 2) gives the statistics
of 72 cases of cancer involving the face, the lips excepted ; of these, 3 died
shortly after the operation, 20 from recidivity, 7 are suffering from a return of
the disease, 8 died from causes other than cancer, 23 still live and exhibit no
sign of recidivity. Of these 23 cured cases, three years or more have elapsed
since the operation in 9 only. Many of these cases exhibited advanced dis-
ease requiring ablation of extensive areas of soft parts and free chiselling of
bone. Ohren confirms Thiersch's observation that "the interval between
operation and recidivity becomes shorter with each succeeding operation."

Extirpation of the Spleen.

Fkhleisen- reports two cases of total extirpation of the spleen for echino-
us cysts {Deutsch. vudiri,,. Wochawhri/f, No. 24, 1888). The first was
operated on in November, 1886, by von Bergmann. The diagnosis lay between
a btr^e and very movable cyst or a wandering spleen. The patient recovered
promptly from the operation. At no time has there been any enlargement of
lands or alteration in the blood. The patient is well and able-bodied.
I second case was operated on in February, 1888. It ran an apyretie
course, and, at the time of reporting, the wound was entirely healed.

hion of a Dislocated Spleent and Subsequent Expectoration

OF Till I.I . ATURE OF THE PEDICLE.

M. <;i:\w reports | Rfci WrttoalR -/.vol. 33. No. 26) a case of splenectomy.

remarkable both in its history and sequel. The patient, at, forty, suffered

SURGERY. 303

from malaria for two year-* ; subsequently received a violent blow in the side,
which confined her to lied for three weeks; then noticed a movable tumor in
the lower part of the abdomen, which grew for a time and was accompanied
by paroxysms of colicky pain, together with suppression of menses. This
continued for seven months, when the menses reappeared. There was an
interval of nine years in which the tumor ceased to grow and the patient
suffered from no distressing symptoms. In 1886, the pain returning, the
patient sought medical aid.

On examination, a tumor of semi-solid consistency was found filling the
whole iliac fossa and extending about an inch over the median line to the
left. It pressed the uterus and bladder far to the left and filled up the right
side of the true pelvis to within two inches of the outlet — immovable, not
yielding to pressure nor changing in position.

An exploratory incision, two inches long, midway between the pubis and
the navel showed that the tumor was not attached to either uterus or ovary.
On enlarging the incision no adhesions were found, the tumor being simply
wedged in between the bones of the pelvis and the pelvic contents. A fuller
examination proved the growth to be an enlarged and dislocated spleen, with
a very long pedicle. It was turned out, the pedicle transfixed and tied, one-
half at a time, the thread being finally knotted about the whole; apyretic
course for one week; pain in left shoulder. Albumin shortly appeared in the
urine, the temperature rose and the patient suffered from pleuro-pneumonia
of the lower lobe of the left lung ; in four weeks from the onset of the pneu-
monia, convalescent; the only troublesome symptom remaining was a per-
sistent pain in front of the left shoulder. The pain continued, together with
a troublesome cough and finally some hemorrhages, for about nine months,
when the ligature applied to the spleen pedicle, still exhibiting the knots
originally tied, was coughed up. This was followed by disappearance of cough
and cessation of the shoulder pain.

For several months after the operation the number of white corpuscles was
increased, the blood containing six times as many in proportion to the red, as
healthy blood. Later the proportion became normal.

MeGraw records another case of splenectomy, undertaken on account of an
enormous tumor which filled up the abdomen to such an extent as to make
breathing difficult. The spleen had contracted adhesions both to the abdomi-
nal parietes and to the diaphragm ; the separation of the latter was attended
by free and persistent hemorrhage. A vein in the pedicle was also ruptured,
but was secured by ligature.

The bleeding from the diaphragm could not be controlled, and caused death
two and a half hours after the operation.

The Operative Treatment of Separation of the Abdominal
Parietes following Laparotomy.

R. Chrobak (Interii'it. klin. Bmmiukmt^ 1887, Noe. 44 and 45) remarks that
bandages and supports are by no means satisfactory in the treatment of the
occasionally enormous hernias which appear at the seat of laparotomy wounds ;
nor is excision of the superfluous skin successful in giving permanent relief.

Chrobak has operated upon two cases with complete success. The cure was

304 PROGRESS OV MEDICAL SCIENCE.

radical, the convalescence uninterrupted and rapid. He divides the thin skin
together with the peritoneum ; the latter is immediately sutured. The super-
fluous skin is resected, and all fat and connective tissue down to the sheath
of the recti muscles is dissected away. By means of strong sutures pene-
trating not only the sheaths but the muscular substance also, the diastasis is
obliterated. A small drainage tube is placed in the wound and the skin is
sutured.

Maydl has operated upon several cases in a similar manner ; he splits the
sheaths of the two recti muscles and unites the sheaths and the muscles of
the two sides separately to each other.

Gastroenterostomy.

Lauenstein (Centralblatt fiir Chirurg., No. 26, 1888) records a case of
gastroenterostomy for carcinomatous obstruction of the pylorus, which termin-
ated fatally from the physiological exclusion of the greater part of the small
intestine, a loop of ileum within sixteen inches of the ileocolic valve having
been opened and stitched to the stomach. The patient, set. sixty-five years,
suffered from pain in the stomach for several years ; from vomiting and con-
stipation for some months. On examination a slightly movable tumor, the
size of a small apple, was found lying near the umbilicus when the stomach
was empty ; carried up to the lower border of the ribs on the right side when
food was taken. The gastric juice contained only a trace of hydrochloric
acid. On opening the abdomen the pyloric tumor was found surrounded by a
number of enlarged glands matted together. Gastroenterostomy was decided
upon ; a moderately full loop of small intestine, lying directly under the
transverse colon, was drawn out and touched with crystals of sodium chloride.
A distinct vermiform motion was shortly perceived passing from left to right,
which Nothnagel regarded as reversed peristalsis.

An opening about two inches long was made in the bowel and stomach,
and apposition maintained by two circles of continued, silk suture. The
opening in the stomach was three fingers' breadth from the border of the car-
cinomatous tissue and one finger's breadth above the greater curvature.
The operation lasted one hour.

No symptoms arose the first two days, except vomiting of bile, which was
repeated three times. Nutritious enemata at first ; after two days bouillon,
milk and wine were given by the mouth, beginning with teaspoonful doses.
Forthwith and till death, nine days later, appeared copious watery evacua-
tions, d:irk brown in color and extremely feculent in odor. Meat appeared
per rectum practically unchanged one-half hour after it had been taken into
the stomach ; there was evidently entire lack of either digestion or absorption,
and the patient perished from inanition eleven days after the operation. On
in, the intestine was found to pass in the opposite direction to that indi-
cated by Nothnagel's test. The opening in the small intestine lay about six-
t. en tnehai bom the ileocolic valve, the fistula was patulous to the thumb, well
t'ornn (1. round and covered through its whole extent with mucous membrane.
'1 'lie phyaiologiealrj excluded intestines were empty and contracted.

In such cases Lauenstein advises careful search for a loop of the jejunum.
which should be stitched to the stomach; this is to be preferred, even though

SURGERY. 305

a larger abdominal wound be required. He also advises that the gut and
stomach should be united by one posterior row of sutures before the opening
is made.

Extirpation of a Cancer of the Large Intestine.

Von Bergmann (Deutseh. medicin. Wochenschr., No. 24, 1888) reports a
remarkable case of intestinal cancer successfully treated by operation. The
seat of disease was the descending colon at the beginning of the sigmoid
flexure ; the nodulated tumor was closely adherent to the concavity of the
ileum. On laparotomy and exposure of the diseased area, a second intestinal
loop, supposed to be small intestine, was found so firmly matted to the mass
that it could not be separated, but, with the diseased colon, was resected.
This resection involved also a large piece of the mesocolon which had be-
come involved in the primary growth or its lymphatic extension, and many
ligatures were necessarily applied to check the very free bleeding. The con-
tinuity of the healthy intestine which had been resected simply on account
of tight adhesions, was restored by a circular intestinal suture ; the two ends
of the colon, however, after the cancer-bearing portion had been cut away,
were stitched to the external wound, making an artificial anus.

On the second day after the operation, high temperature, tympanites, pain
and vomiting pointed to the development of peritonitis. The wound was
opened again and the resected ends of intestine, which had been sutured
together, were drawn out. A portion near the line of suture was discolored
and clearly gangrenous ; the thread was removed and both ends secured to
the external wound ; the latter now contained four intestinal lumina. The
general condition of the patient improved, pain and swelling disappeared,
the wound suppurated. Almost four weeks later a gangrenous piece of in-
testine nearly a foot long was discharged. The suppuration diminished, and
there remained simply an artificial anus, about the size of a silver dollar,
from which folds of prolapsed mucous membrane projected.

In .March, when an examination of this opening was made with a view to
its closure, in place of four intestinal openings but two were found, separated
from each other by a thick partition wall. This was explained by the fact
that both loops of resected intestine were from the colon ; the portion between
the two resections having sloughed, probably on account of its circulation
being cut off" by the many ligatures applied while removing the diseased
mesocolon, was discharged en manse, and left only the extreme upper and
lower intestinal extremities adherent to the surface wound.

Extirpation of the Rectum.

Bardenheuer exhibited his method of operating to a number of the
members of the Surgical Congress (Beilage zum Centra/tdaff fiir OMntrg.,
No. 24, 1888). The patient was an old woman suffering from a cancer ex-
tending to the breadth of several fingers above the sphincter.

Operation. — Dorsal position, with elevation of the buttocks. The incision
in the middle line exposed the coccyx and lower portion of the sacrum ;
removal of the latter by means of the bone forceps. The sphincter was not
divided. The unopened rectum was freed from adhesions by means of tearing

806 PROGRESS OF MEDICAL SCIENCE.

with the fingers and blunt instruments, a provisional ligature was placed in
the healthy parts above and below, and the tumor was excised. After closure
of a peritoneal rent made while isolating the tumor, the continuity of the
bowel was again restored by suturing the upper and lower ends together.
The sacral wound was left open, the cavity about the rectum being carefully
tamponaded with iodoform and iodide of bismuth gauze, and a thick rubber-
tube was placed in the rectum.

The duration of the operation was thirty minutes. Bardenheuer has
operated in this manner upon thirteen cases, losing two; one from exhaus-
tion in twenty-four hours, one from the rectum being constricted in a rent of
Douglas's pouch and becoming gangrenous.

Ki>ni<; (foe. <-it.) subjects his patients to a preparatory course lasting from
four to eight days, thoroughly emptying the bowels and withholding food
which leaves much detritus. A posterior central incision is made and the
bowel torn loose with the finger, often high above the peritoneal attachment.
All involved lymphatic glands are removed. The wound is thoroughly
washed out with antiseptics (carbolic or salicylic solution), sprinkled with
iodoform and either packed with iodoform gauze, after the insertion of a few
sutures, or drained by means of numerous deep sutures passing to the rectal
walls.

Of the sixty cases operated upon, twenty-four per cent, died; ten per cent,
remained cured after three years; eighteen per cent, after two years. Three
patients suffered from recidivity after they had remained well for upward of
three years.

In regard to the function of the new rectum, of twenty-one patients exam-
ined, but six were able to retain their feces ; three suffered also from stenosis.

Von Bergmann (loc. cit.) considers that the danger of rectum extirpation
is very much lessened, and prefers this procedure to colotomy; he mentions
r.iamann's success in this operation — of twenty-seven cases, twenty -six
recovering.

Hemorrhoids.

Mr. Whitehead describes {British Medical Journal, February 26, 1887)
an operative procedure for the radical cure of hemorrhoids which he has em-
ployed in upward of three hundred cases, with complete success in the sequel
and such a favorable course during treatment that in no instance have symp-
t 'in- arisen which have given him cause for serious anxiety. The operation
-ista in thoroughly paralyzing the sphincters by digital stretching; divid-

ihr mucous membrane around the entire circumference of the anus, a
short distance from its junction with the skin, by means of scissors and dis-
secting forceps, and disserting the whole diseased or pile-bearing area from the

mal and internal sphincter until healthy mucous membrane is reached,

D it is drawn down and stitched to the skin, the hemorrhoidal mass being
removed.

Am. iv. ii \m (Medioal ftest, June 27, 1888) finds the chief disadvantages of

method to consist in "the lax and irregular condition of the anus and the
resultant trouble in separating the mucous membrane from the skin ; the time

required In twisting the vessels in had cases and the length of the operation."
To obviate these difficulties he has devised an instrument with four arms,

SURGERY. 307

each of which seizes the mucous membrane at its junction with the skin, and
cum be made to separate from its fellows by means of a screw, converting the
anus into a s juare-looking aperture. The line of incision separating skin
from mucous membrane is now clearly defined, and by using the instrument
as a handle the parts can be held in the most favorable position for rapid
lection up to the internal sphincter. Opposite the position of each large
pile i thread is. passed through the skin around the stems of the pile, brought
out through the skin again and tied tight enough to prevent hemorrhage. The
drawn-out pile area is cut off just in front of the ligatures, the mucous mem-
brane is sutured to the skin and the parts powdered with iodoform.

Wkir reports {The MmKcalllecord, vol. xxxiii.,No. 26, 1888) six severe cases
of hemorrhoids treated by the Whitehead method. In all, the results were
-factory. The convalescence was rapid and the cure complete. In
regard to the choice of operative procedure, he says :

" While for less severe cases of hemorrhoids the operation of injection with
carbolic acid (and preferably with the 1 : 20 solution) is to be first thought of,
and while for the more decided form of this disease Allingham's method (liga-
tion) yet stands unequalled, yet for extensive conditions of hemorrhoidal dis-
ease which have been hitherto treated by tying off three, four, and sometimes
more masses, I believe that greater efficacy and greater permanence of cure
will be accomplished by the resort to Whitehead's method, and that less after-
discomfort to the patient will be felt than by the well-known method ot
ligature."

Fracture of the Skull.

Three cases of trephining for fracture of the skull, associated with a wound
of the middle meningeal artery, are reported by Bru>*ner (Correspondenz
lihtt/ilr srhica'tz. Aertzie, No. 12, 1888).

1. Compound, comminuted, depressed fracture of the skull. Laceration of
the dura mater and brain substance. Rupture of the middle meningeal artery,
with external bleeding.

The portion of the brain involved in the laceration was included in the
r part of the ascending parietal and superior temporal convolution. The
scalp was shaved and washed with ether, soap and sublimate solution 1 : 1000.
The wound was enlarged, and hair, bone, splinters and torn brain tissue were
carefully washed and picked from its depth. The bleeding which came from
the anterior branch of the middle meningeal could not be reached directly
and was checked by iodoform gauze tamponade. Drainage, strict antisepsis,
uninterrupted recovery. Neither before nor after operation was there loss of
consciousness, disturbance of sensibility or paralysis. Two years afterward
the patient was without symptoms and entirely able-bodied.

2. Compound, comminuted, depressed fracture of the skull, with laceration
of the dura, escape of brain substance and rupture of the anterior branch
of the middle meningeal artery ; external bleeding.

External wound, one and three-quarters inches long, extending from a point
three inches from the root of the nose and one and three-quarters inches from
the central line to about the origin of the attolens aurem muscle. On en-
larging, an area of bone, equal in size to the palm of the hand, was found
comminuted and driven in upon the brain substance.

308 PROGRESS OF MEDICAL SCIENCE.

Patient semiconscious, paralysis of the leftside of face and of the right arm
and leg, the latter not well marked ; involuntary passage of urine and feces.
Clots, fragments of bone, hair, and torn brain substance were removed. To
check bleeding thoroughly the bone was chiselled away until the main branch
of the anterior meningeal artery was exposed, when a curved needle armed
with a ligature was passed around it. Immediately after the operation con-
sciousness returned and the patient was able to move the right arm and leg.
Prompt healing of the wound and disappearance of brain symptoms.

3. Comminuted fracture of the left parietal bone, not compound. Rupture
of the middle meningeal artery. Supradural hematoma. Crossed paralysis.
Trephining and removal of the exudate. Death from pneumonia.

In this case the symptoms usually considered as diagnostic, i. e., 1, an
interval of freedom from marked symptoms after an injury ; 2, gradual devel-
opment of hemiplegia; 3, the typical pressure pulse; 4, stertorous respira-
tion ; 5, signs of a head injury, were all present. The skull was trephined
at Kronlein's point of election, i. e., the crossing of a horizontal line passing
backward from the supraorbital margin and a vertical line extending upward
from immediately behind the mastoid process, The clot was found to lie ante-
rior to this opening. A second trephine opening was made at Vogt's point
(middle meningeal), the clot cleared away and the bleeding checked. No
immediate change in symptoms; gradually the sensibility returned and power
of motion. Death on the seventh day from lobular pneumonia.

Bardeleben reports (Deutsch. medicin. Work., No. 24) a case of comminuted
fracture of the skull, in which the wound lay directly over the centres for
speech, facial expression (except the eye) and the motion of the forearm.
Several hours after the extraction of some bone splinters the patient regained
consciousness. The second day was characterized by an increase in the dis-
turbance of speech and paralysis of face and forearm. On the evening of the
third day the right arm and leg were suddenly affected with spasms lasting
five minutes. These spasms recurred at intervals during the next five days,
involving the arm and face, and, finally, the face alone. All symptoms
gradually ameliorated, till, in four weeks from the operation, some weakness
of the right hand was the only motor trace of the injury left.

OPHTHALMOLOGY.

UNDER THE CHARGE OF

GEORGE A. RERRY, M.B., F.R.C.S. Eni> :..

OPHTHALMIC Sl'MCO!) TO THE ROYAL INFIRMARY, KDINBCROH.

A New Practical Ophthalmometer.

In tlu> February number of the Rrvur >!' Ophthalmologic, LEROYand DUBOIS
describe an ophthalmometer which they claim to be capable of famishing
more correct results tlian the well-known instrument of Javal, and which,

OPHTHALMOLOGY. 309

besides, has the advantage of being very considerably cheaper. Since the
introduction of Javal's ophthalmometer many points of interest have been
studied in connection with the different relations existing in different cases
between the amounts of corneal and lenticular astigmatism. The instrument
has also proved useful as a means of following the changes in corneal curva-
ture which take place after operations, etc. Such an ophthalmometer, though
hardly a necessary addition to the requirements of the practical ophthalmic
surgeon, is yet so easily worked that it can undoubtedly lay claim to being a
practical instrument.

In Leroy and Dubois's ophthalmometer a definite size of corneal image
(0.044 inch) is taken, as well as a definite distance of object and image,
and from the size of object corresponding to this image the calculation is
made, once and for all, of the corresponding radius of curvature and conse-
quently of the retractive power of the cornea. The image is known to be of
a definite size when exactly double by an arrangement similar to that used
by Helmholtz, and the distance is regulated by the focus of the telescope
which carries the object the image of which is reflected from the cornea. This
object is a graduated horizontal bar, at either end of which, and about
eight inches apart, is a sight, one of which is divided into rectangular marks,
alternately black and white and 0.196 inch in breadth. All that is necessary
in making a measurement, after the instrument has been got into position,
is to observe which of these rectangular intervals of the one sight exactly
covers the sight on the other side, when the image on the cornea is doubled,
and then to read off the number corresponding to the position of the rectangle,
a number which is given in dioptres. A reading taken from any two meridians
at right angles will thus give the value of the corneal astigmatism. The
meridians of greatest and least curvature, which determine the position
required for the axis of the correcting glass, are found in the following way:
having discovered the difference in the refraction of the cornea in any two
meridians at right angles to each other, that meridian is found the image of
which corresponds to an object intermediate in size between the first two.
The meridians of greatest and least curvature lie at angles of 45° to either
side of this meridian.

CONJCNCTIVITIS AESTIVALIS.

An important paper on spring catarrh is contributed by Hansen Grut in
the first number of the new Scandinavian ophthalmological journal [Nordiak
Ophthalmologist T\dt»kr\ff), of which he is the editor. The subject is very in-
differently treated in the text-books. The following is a resume of Grut's de-
scription :

The affection begins in spring or summer with subjective symptoms similar
to those of an ordinary conjunctivitis, though there is but little increase in the
secretions. Generally there is a circumscribed injection of the peri-corneal
vessels and in this situation small gray, semi-transparent, nodules of a carti-
laginous consistency make their appearance. Often there are no distinct
nodules, but a continuous and swollen infiltration at one part of the conjunc-
tiva surrounding the cornea. The swelling, though it may to some extent
overlap the cornea, is always clearly defined, and the cornea remains per-

310 PROGRESS OF MEDICAL SCIENCE.

fectly clear, while the immediately surrounding portions of the conjunctiva
assume a whitish appearance. The accompanying objective and subjective
symptoms are subject to exacerbations and remissions during the course of
the disease. They diminish in the autumn, the infiltrations flatten down or
disappear, leaving, however, a certain degree of opacity just at the border of
the cornea ; the following spring the attacks recur and this state of matters
may continue for years.

The form just described is the mildest and seems to be the best known.
Often on everting the lids the surface of the tarsus, especially of the upper
lid, is found to be whitish, as if covered with a thin layer of milk. In more
severe cases the tarsal portion of the conjunctiva of the upper lid is covered
with flattened granulations, the edges of which lie close up to each other.
By pinching up the everted lid from side to side the separate granulations
come into prominence, showing too the deep furrows which exist between
them. A thin probe can then be passed in under them, so that they can be
shown to be mushroom-shaped, each being perched on a narrow pedicle.
The granulations cause the eyelids to droop, and the appearance at first sight
closely resembles that met with in trachoma. These flattened granulations
are the most characteristic changes in the severer cases and, although they
do not altogether disappear in winter, they are subject to the same exacerba-
tions as are met with in the conjunctival swellings surrounding the cornea.

Hansen Grut believes that the disease is often mistaken for trachoma and
gives the following points of differences by which they are clinically sharply
defined : the trachomatous granulations never lose their rounded surface and
are not separated by deep furrows, whereas those of spring catarrh are flat-
tened and separated by furrows. Trachoma leads to cicatricial changes, deep-
seated linear cicatrices. The infiltration in trachoma passes into the tarsus,
leading to alterations in its shape, to trichiasis and to entropion. This never
occurs in the case of the granulations characteristic of spring catarrh ; when
the disease, after many years' duration, has disappeared the conjunctiva is left
smooth and whitish, but is not the seat of any actual cicatricial formation and
the tarsus retains its form. A long-continued trachoma is almost always
associated with pannus. In spring catarrh, on the other hand, the cornea is
never affected. This is of prognostic importance and, besides, interesting
as showing that trachomatous pannus has not a mechanical origin — that is,
is not set up by the friction of the uneven surface of the lid on the conna.
This is more especially evident from the fact that the spring catarrh granula-
tions are much harder and often more massive than those found in trachoma.
The granulations never appear on the lower lid.

Notwithstanding the great chronicity of spring catarrh and its rebellious-
ness to any treatment, cases are occasionally met with in which all the
changes disappear in an almost incredibly short space of time without leaving
a traer. An instance of this is cited: a case which had been under the
writer's treatment since 1866, in which, after puerperal fever, which occurred
many years afterward, there was a complete cure, although massive irranula-
fetons had existed tor sixteen to eighteen years. The granulations differ aiao
anatomically from the trachomatous form and consist mainly of a hyper-
plasia of the superficial elements of the conjunctiva. The affection is alwi
bilateral and is met with in children and in adults under thirty-hve years.

OPHTHALMOLOGY. 311

With reference to the name "spring catarrh "the following remark may be
quoted: ''It has been generally supposed that the disease has an intimate
connection with the warmer seasons of the year and comes and goes with
those seasons; hence its name. I have already mentioned that the granula-
tions, at all events, do not disappear in the winter. It is doubtful, indeed, if
the summer exacerbation, which certainly takes place, is the most character-
istic phenomenon in connection with the affection. The same holds good of
other chronic diseases of the conjunctiva. Phlyctenular conjunctivitis flour-
ishes in spring and summer ; the severe exacerbations of trachoma also take
place during the warmest summer weather. Heat, with dry air and dust, is
certainly irritating to a mucous membrane disposed to inflammation."

The treatment recommended is the destruction of the granulations with
the thermo-cautery ; sulphate of copper and nitrate of silver do harm.

Traumatic Paralysis of the Sixth Nerve.

Purtscher has made a very exhaustive examination of the literature of
traumatic paralysis of the sixth nerve, a report of which he gives in the June
number of the Archivfiir AugenkeUhmde. The cases are classified in different
ways, according to the nature of the complications caused by the injury which
has given rise to the adducens paralysis. Traumatic paralysis of the sixth is
rare in comparison with the frequency of injuries to the skull, though rela-
tively common as an isolated paralysis. Bilateral paralysis is much more
frequent in the traumatic than in the idiopathic cases. Most frequently,
when the paralysis occurs on the one side alone, it is on the side of the injury.

On Certain Pupillary Changes met with in Chronic Pulmonary

Disease.

Comini (A>ina/i di Ottamologia, 1888) gives the histories of nine cases in
which he has observed mydriasis in phthisis. Most frequently it occurred
on the right side, coincidently with an alternation at the apex of the lung
on the same side. Sometimes it was bilateral. Photophobia and paresis of
accommodation accompanied the mydriasis in some cases. The dilatation of
the pupil was sometimes transitory, though it did not ever appear, as main-
tained by Rampoldi, who first described the form, to stand in any direct con-
nection with the temporary aggravation of any of the symptoms. Rampoldi
believed the cause to be a reflex irritation, as in the case of mydriasis proceed-
ing from irritation of the mesenteric plexus. Comini suggests that possibly,
sometimes at all events, the sympathetic may be directly involved in the
disease.

The Donders "Festschrift."

In accordance with the law of Holland, professors at the universities are
obliged to retire when they have attained the age of seventy years. On the
occasion of the retirement of Professor Donders, which took place on the
27th of May, he was presented by a number of his former pupils with a Fest-
schrift, in the shape of a handsome volume, containing original contributions
from forty different authors. The volume embraces treatises on various

312 PROGRESS OF MEDICAL SCIENCE.

medical subjects, only fifteen of which are purely ophthalmological. Of these
fifteen, the following are the most important: van Moll, On the Absence of
Torsional Movements on Lateral Fixation; Straub, On the Anatomy of the
Corpus Vitreum ; van Braam Houckgeest, The Superior Oblique Muscle ;
Nuel. On the Treatment of Corneo-scleral Ruptures ; Hamburger, The
Influence of the Section of the Optic Nerve in Frogs on the Movement of
the Pigment in the Cones and Retina; Mulder, Vertical Lines as seen
with the Head bent to either Side; Snellen, Myotics and Sclerotomy in
Glaucoma. Most of these are, as will be seen, of a theoretical nature and
do not call for further consideration here.

Nuel draws attention to the fact that rupture of the external coats of the
eye, caused by severe contusions, takes place, in the immense majority of cases,
concentrically with the corneo-scleral border. He points out very correctly
that the site of such ruptures corresponds to the angle of the anterior chamber,
so that they do not involve the ciliary body, as is so often assumed to be the
case. To this circumstance is to be ascribed the comparatively favorable
course which accidents of this nature are likely to take, as far as the super-
vention of any severe inflammation, leading to destruction of the eye, is con-
cerned. There is, however, often a tendency for the wound in the sclera to
remain open ; so that the anterior chamber is either only imperfectly or not at
all re-formed, while the aqueous accumulates below the conjunctiva and raises
it in the form of a bleb in front of the wound. Nuel recommends for such
cases a treatment which he has found very successful. It consists in performing
with a narrow knife a sclerotomy through the wound and drawing the sur-
rounding conjunctiva over it by means of a suture placed in an original
manner. The object of the operation is to cover the wound with as thick a
mass of superficial tissue as possible. To effect this, the knife, after cutting
through the tissues filling up the space between the lips of the wound in the
sclera, is directed backward, so as to cut out a deep flap of conjunctiva. A
suture is then placed in the following manner: it is entered at the equator
of the eye as far back as possible and passed out and in (basted) through the
conjunctiva for a considerable distance, parallel with the corneo-scleral
margin. The needle is then carried diagonally over to the conjunctiva im-
mediately surrounding the cornea at the opposite end of the wound and the
thread basted in a similar manner close to the cornea and finally brought
out beyond the wound at the other side. The two ends of the thread are
then tied tightly together. In this way a large mass of conjunctiva is puck-
ered up over the wound in a much more efficient manner than could be done
by the introduction of a number of sutures in the ordinary way.

Snellen refer* to v. Graefe's caution against substituting sclerotomy for
iridectomy and ascribing the effect of iridectomy to the wound in the corneo-
scleral margin. He points out, however, that at that time the value of myotics
and the combination of myotics with sclerotomy as a means of reducing ab-
noi ■•iially increased tension was not known. Snellen recommends the latter
incut as a suitable one to begin with in most eases, ax, if not successful,
hi be followed by iridectomy. In two cases in which he simultaneously
rme.l iridectomy on one eye and sclerotomy on the other, followed by
pilocarpine, the sclerotomized eye retained the best vision. In both cases,
though, it was the last to be attacked by the glaucoma. He has observed

LARYNGOLOGY. 313

complete and permanent cure of glaucoma result from sclerotomy. In one
case twenty years have elapsed since the operation. Snellen considers myotics
of prognostic value. When under their action the pupil contracts and the
tension is diminished, a good effect may be expected from an operation. He
ribes a case of glaucoma in an eye with irideremia and refers to the two
similar cases published by v. Graefe. In this case the tension was reduced
by the use of pilocarpine, which he believes can only be ascribed to its action
on the ciliary muscle. He makes the following suggestions as to the manner
in which sclerotomy and myotics favorably influence the glaucomatous pro-
cess : " The circular fibres act in the same direction as the contraction of the
pupil, viz., toward the axis of the eye. The base of the ciliary body must
thereby be drawn inward. Contraction of the meridional fibres is supposed
to draw the anterior attachment backward and the posterior one forward.
As by increased tension the uvea is pressed against the sclera and its dis-
placement rendered less easy, the contraction would be more appreciable in
the anterior part and, by dragging on the anterior wall of Schlemm's canal,
would release the tension on the tissues further back. A portion of the radial
fibres end in the membrane of Descemet. Might it not be supposed that from
a sclerotomy, aided by a strong myosis, the posterior lamellae of the cornea may
be so extended that a gaping wound results in Descemet's membrane, which,
otherwise, owing to its endothelial covering, is impervious." This supposi-
tion of a patency of the inner portion of the scleral section remaining per-
manently is considered by Snellen to be supported by the flattening of the
cornea and consequent astigmatism which are so commonly observed after
sclerotomy.

DISEASES OP THE LARYNX AND CONTIGUOUS
STRUCTURES.

r.VI'KR 'IMF. CHARGE OF

J. SOLIS-COHEN, M.D.,

Or PHILADELPHIA.

The Influence of Diathesis in Diseases of the Larynx.

Dr. Senac-Lagraxge, in an elaborate article (Annates da mal. de Torexllt,
du larynx, etc, Mai et .Tuni, 1888), contends that there is a prominent etio-
logical element in all laryngeal inflammatory diseases due to dynamic condi-
tions, and indicated by paretic or by contractural conditions as presented in
the subjects of the lymphatic or of the arthritic diathesis, or of the hybrid
resultant in which lymphatism is usually predominant.

11. rapports this new theory in etiology by numerous examples taken from
the records of cases of dysphonia, paralysis, spasm, catarrhal and glandular
laryngitis, syphilis and tuberculosis; and by tracing the connection between
the diathesis, which has usually escaped the cognizance of the recorders,
though distinctly indicated in their clinical histories, and the accurate
ptions of the anatomical changes detailed.

VOL. 96, KO. 3.— SEPTEMBER, 1888. 21

314 PROGRESS OF MEDICAL SCIENCE.

Thia differentiation of species, it is claimed, can be successfully utilized in
the constitutional treatment of laryngeal maladies, and, likewise, in topical
treatment; support being given in the atonic lymphatic class of cases, and
modification by substitutive action in the arthritic class, thermo-alkaline
waters being indicated in the latter group and saline alkaline in the former,
whatever the character of the lesion.

On the Transformation of Benign Laryngeal Growths
into carcinomata.

The editor of the Internationales Centralblatt fur Laryngologie, etc., Dr. Felix
Semon, of London, states, in the issue for July, that while he has not yet had
time properly to prepare, in detail, the material he has collected, he can
announce the fact that apparent transformations have been reported in 32
instances only out of 8216 intralaryngeal operations upon morbid growths, a
proportion of less than one-half of one per centum. Further analysis of
these 32 cases shows that 16 of them are quite questionable, 12 of these being
recorded as doubtful by the reporters. Hence the proportion is reduced to
less than one in five hundred, or a proportion of 1 : 513.

Cancer of the Larynx.

In a critical review [Le Progres Medical, May 19, June 9, 23, and July 17,
1888) Dr. J. Baratoux presents first an historical bibliographical summary
of the literature from Morgagni to Schwartz (1886). According to this review,
statistical records show that carcinoma has occurred in the proportion of about
one case in every three hundred of laryngeal disease as seen by laryngologists.
Intrinsic carcinoma is almost always located above the glottis, and is much
more frequent than extrinsic carcinoma. Carcinoma is much the more fre-
quently unilateral, the left side being affected far oftener than the right.

Baratoux includes sarcoma, epithelioma and carcinoma in his category of
cancer. Sarcoma is the least frequent, and the fasciculated variety is much
more frequent than the globocellular. Sometimes it is of the mixed variety.
Lymphosarcoma, alveolar sarcoma and myxosarcoma have been noted like-
wise. Epithelioma is the most frequent variety of cancer, comprising nearly
four-fifths of the whole. Nearly all examples have been lobulated. Car-
cinoma proper occurs in the proportion of about three to twenty. The cause
of cancer is uncertain. Topical irritation precedes in some instances. Hered-
itation is evident in others. It has been observed occasionally in associa-
tion with tuberculosis.

Cancer has been observed in the very first year of life, and as late as the
ninth decennium; but more than half of the cases were between the ages of
forty and sixty years. It is far the more frequent in the male, occurring in
the proportion of about seven to one in the other sex.

Involvement of the lymphatic glands occurs in intrinsic cancer as well as
extrinsic, but in far less proportion. It is usually unilateral, involving one
or more glands along the border of the sternomastoid muscle. In intrinsic
cancer the first gland to be affected is one at the anterior border of the muscle
at a level with the thyro-hyoid ligament; in extrinsic cancer it is the inferior

LARYNGOLOGY. 315

cervical ganglions which become implicated. This involvement is rarely early.
It may become sufficiently voluminous to compress the trachea injuriously,
it may contract adhesions with adjoining tissue, and it may undergo inflam-
mation and ulceration. On the other hand, it must be remembered that all
enlarged glands are not cancerous.

The indications are given for the differential diagnosis of the varieties of
cancer from each other, and from tuberculosis and syphilis. The methods of
treatment are discussed in detail and the most complete tables of the various
operations and their results yet published are given.

Baratoux concludes that extirpation of the larynx is the best method of
obtaining a favorable result, especially if the diagnosis has been made early,
because it not only prolongs life but renders it supportable.

In discussing palliative treatment Baratoux recommends most highly tinc-
ture of arbor vita, both topically and internally, in doses of 15 to 30 grains.
He cites the case of a female whose life had, at the time of writing, been
prolonged forty months by this remedy, although the cancer involved the
palate, posterior palatine folds, uvula, tonsils, lateral walls of the pharynx,
the epiglottis and the vocal bands. The same remedy has long been vaunted
for cutaneous warts and in cancer of the uterus.

In reporting (Rev. Mens, de Lar., etc., June, 1888) a case of cancer of the
larynx in which tracheotomy was performed because his patient declined to
submit to a proposed laryngectomy, Dr. J. Charazac, of Toulouse, com-
pares the results from this palliative operation with those of the radical one
and concludes that the latter is the proper procedure in all cases strictly
limited to the interior of the larynx, before there has been any contamination
of the glands and while the general health remains unimpaired. Confined to
cases of this kind he anticipates increasing successes from the operation.

Chronic Abscess of the Stump of ax Ablated Tonsil.

Dr. Noquet relates (Rev. mens, de Lar., July, 1888) an unusual instance
of abscess of the stump of a tonsil communicating with the exterior by a
small fistule, from which pus had exuded daily for six months, in a married
female, twenty years of age. She had in infancy been the subject of ton-
sillar hypertrophy. The right gland had been excised at about six years of
age; the left about six months previously to examination. The stump, at
the border of the palatine folds, was very red and notably hypertrophied,
and, on pressure, pus exuded from a fistule. An incision with the electric
cautery released about a teaspoonful of pus. After several cauterizations a
cure was effected.

The Parasitic Nature of Acute Coryza.

Dr. F. Cardone, of Naples, contends (Archiv Rjduini di Laringologia,
Luglio, 1888) that the morbid process in acute coryza is analogous to that of
pneumonia. The acute initial stage, the type of fever, the course, the critical
defervescence, the character of the secretions, the prostration of the patient,
the ready transference of the affection to the inferior tract of the respiratory

316 PROGRESS OF MEDICAL SCIENCE.

passages which characterize coryza have great analogy with the course of
pneumonia ; a consideration emphasizable from the fact that the nasal
mucous membrane is the first portion of the respiratory tract. This opinion
was expressed in 1886 by Massei, Trifiletti and Meyer.

In examining the secretions Cardone has found the streptococcus pyogenes,
the staphylococcus aureus et albus and, in greater quantities, the diplococcus of
Frankel and the pneumococcus of Friedlander.

Cephalalgia from Intranasal Disease.

Under the caption Des Cephalees de Croissance, previously adopted by Dr.
Ren6 Blache, Dr. Joal discusses (Rev. mens, de Lar., etc., July, 1888) a
certain class of headaches which occur about the period of puberty. Blache
attributed them (1883) to disproportion between cerebral activity and efforts
of intelligence ; Keller, some months later, to a dolorous neurosis of the
brain. Perin and other ophthalmologists attribute them to asthenopia.
Hack (1883) claimed that they were due to intranasal disturbances, and he
has been supported by Ruault and others. Joal reports in detail two con-
firmative instances in a male subject, fifteen years of age, and in a female,
aged fourteen years. There was a genital complication in each of these in-
stances, the symptoms becoming aggravated, in the one case, during two
attacks of preputial herpes and, in the other, at the menstrual period. Hence,
Joal is led to sustain the opinion of Mackenzie, of Baltimore, that excitation
of the sexual apparatus should be considered a factor in the production of
diseases of the nares.

Dr. Mknikre [Ibid.) relates an instance of daily cephalalgia of two years'
duration cured by intranasal cauterizations and ablation of adenoid masses.

Symptoms of Diseases of the Sphenoidal Sinus.

Dr. Emile Berqer (Rev. mens, de Lar., July, 1888), in order to learn the
symptoms by which diseases can be detected during life, has carefully studn d
the records of all reported cases in which disease of the sphenoidal sinus has
been found postmortem. Caries and necrosis present the following group of
symptoms: 1, sudden unilateral blindness, with phlegmon of the orbit; the
origin of the blindness being perineuritis of the optic nerve in the optic canal ;
2, slow detachment of fragments of bone, without ocular troubles ; and, finally,
meningitis; 3, sudden discharge of a large quantity of bone by the nose;
4, fatal hemorrhage after perforation of the wall between the sphenoidal and
the cavernous sinuses; 5, retropharyngeal abscess; 6, thrombosis of the
sinus and of the ophthalmic vein, due to thrombosis of the circular venous
sinus of the sella tmreica; 7, perforation of the inferior wall of the sphenoidal
sinus, without any other symptom. In cases of tumors of the sphenoidal
sinus, four periods can he distinguished: 1, when the tumor is limited within
hy the walls of the sinus, there may be no symptoms, or cephalalgia only; 2,
when the tumor, by its growth, dilates the walls of the sphenoidal sinus, pro-
ducing their atrophy and compressing adjoining organs; the compren
in iv involve one or both optic nerves and produce amaurosis; 3, when the
tumor may propagate beyond the walls of the sphenoidal sinus; it may ex-
tend into the nasopharyngeal cavity, into the ethmoid cells, into the orbit

OBSTETRICS 317

and, finally, into the cranial cavity; perforation of the base of the cranium
may occur without any symptoms or may excite very grave cephalalgia;
4, metastases are observed in various organs. Epileptic seizures often take
place. If the tumor grows rapidly, then meningitis or cerebral abscess occurs
soon after perforation of the base of the skull.

Wounds of the sphenoidal bone may produce the following symptoms: 1,
in fissures of the superior wall of the sinus, continuous trickling of cerebro-
spinal fluid; 2, rupture of a fragment of the body of the bone may wound
the internal carotid to the inside of the cavernous sinus and cause pulsating
exophthalmia ; 3, continuation of the fissure in the canal of the optic nerve
will cause compression or rupture of the optic nerve and, consequently, amau-
rosis ; 4, if the fissure extends to the oval or round foramen, it will produce
anaesthesia of the second and third branches of the trifacial, and a rupture or
wound of other and cerebral nerves may present simultaneously.

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

VI8ITI.NO OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL.

A Case of Sextuple Pregnancy.

Vassalli, a physician of Castagnola near Lugano, Switzerland, reports a
case of premature labor with sextuple births at four months pregnancy. The
sexes were unlike, the foetuses fully formed ; there was one placenta. The
father belonged to a prolific family, and by a previous marriage had ten
children. Statistics show that the district of Castagnola is peculiar for mul-
tiple births. The specimen has been placed in the Royal School of Obstetrics
at Milan — JMH$k Hectical Journal, June 9, 1888.

The Results of Precipitate Births.

Goltz (Coresponilenz- Bint* {>• I rtze, No. 9, 1888) has collected

thirty-seven cases of precipitate births, from the study of which he draws the
following conclusions : These cases do as well as the average normal labor ;
their complications are moderate hemorrhage and fever, and delayed involu-
tion of the uterus; these complications occurred frequently, but resulted
favorably. None of the patients had the assistance of skilled or unskilled
persons ; no sepsis was observed among them.

The children suffered from conjunctivitis, catarrh, and showed a slight
scalp tumor, which rapidly disappeared. The maternal mortality was almost
nothing ; that of the children was 26.8 per cent.

Embryotomy.

Budin (Le Progrls M&dieat, Not 18 and 19, 1888) in his clinic described a
case of neglected shoulder presentation which came to his attention when the

318 PROGRESS OF MEDICAL SCIENCE.

foetus was dead and impacted in the pelvis. The uterus was contracted
firmly upon the foetus.

Vt r>ion being considered impossible, embryotomy was done with Tarnier's
embryotome. This instrument consists essentially of a hook carrying a
sheathed linked saw, which is gradually tightened after being placed in
position. The foetus was divided at the upper extremity of the thorax. The
trunk was delivered by traction ; the head was expelled spontaneously. An
intrauterine douche of two quarts of bichloride of mercury, 1 to 2000, was
given ; the patient made an uninterrupted recovery.

Budin prefers Tarnier's embryotome as less dangerous to the maternal
tissues than any form of scissors.

Extrauterine Pregnancy, treated by Laparotomy.

Herman {Lancet, May 26 and June 2, 1888) reports two cases of early
extrauterine pregnancy, cured by laparotomy, the dilated tube and ovum
being removed, hemorrhage checked and the abdomen cleansed. In a third
case operation was delayed, but when performed revealed a ruptured Fallo-
pian tube, with clotted blood: the patient succumbed. In this case, before
operation, the haematoma had been opened, a drainage tube inserted and the
cavity washed out, but hemorrhage persisted until the tube was removed.

Herman believes that many cases recover spontaneously, by absorption of
the larger portion of the ovum. Puncture and electricity are not to be relied
upon. Early abdominal section gives best results when treatment is indicated.

An Interesting Case of Eclampsia.

Charpentier {Bulletins de la Societi Obstetricale, No. 6, 1888) reports the
case of a primipara, six and a half months pregnant, in whom albuminuria
was detected on several occasions by different physicians, and appropriate
treatment ordered: this was persistently neglected.

Eclampsia supervened suddenly, at night, without warning; a condition of
partial coma followed which persisted until treatment had been employed for
forty-eight hours; the urine was extremely rich in albumin. Coma was fol-
lowed by convulsions, in the first of which the foetus perished. Temperature
and pulse remained normal. Epigastric pain and headache were the symp-
toms; disturbances of vision did not develop until forty-eight hours after
albuminuria and convulsions had ceased.

Labor was not attended by convulsions; dilatation of the cervix was slow,
but there was no post-partum hemorrhage; the puerperal period was normal.

Puerperal Septicemia with Gangrkm : ELXOOYXBT,

Charm EM i ii.k {Bulletins de la Socilti Obstitricale, No. 6, 1888) reports the
case of a primipara in whom septicaemia followed the normal delivery of an
adherent placenta. Diphtheritic ulceration, with gangrene of the superficial
tissues, developed.

The uterus was curetted with a dull curette, and swabbed with creasote and
glycerin (1 to 2); an intrauterine douche of bichloride of mercury, 1 to 2000,
was given, and iodoform gauze was applied to the vagina; quinine and alcohol

OBSTETRICS. 319

were freely administered. Great improvement followed; five days afterward
septic pleurisy developed on the left side. The patient made, however, a
rv without further operative treatment.

A Case of Purulent Puerperal Peritonitis; Drainage; Recovery.

Woodward [Boston Medical and Surgical Journal, July 12, 1888) reports a
case of purulent puerperal peritonitis to which he was called about six weeks
r labor. An extensive accumulation of pus in the abdomen, and septi-
caemia were diagnosticated. The abdomen was opened, offensive pus
evacuated and the cavity irrigated with hydronapthol (1 to 1100) ; a drainage
tube and antiseptic dressing were applied. After repeated irrigation with
boiled water and constitutional treatment the patient recovered.

The abscess had at first been circumscribed, but thirty-six hours before the
operation had burst into the abdominal cavity. Recovery, under these cir-
cumstances, was remarkable.

Air-embolism or Placenta Pr.evia.

Kramer [ZeiUchrift fur Geburtehiilfc, Band 14, Heft 2) reports a case of
placenta praevia (centralis) in which turning was just accomplished when,
following a uterine contraction and contraction of the abdominal muscles,
the patient collapsed and died.

Post-mortem examination revealed the right heart distended with air : in
the deeper layers of the decidua the open mouths of veins were seen, through
which air had entered. No air was present in the uterine veins ; that which
entered when the uterine and abdominal contraction relaxed and the blood-
pressure in the abdominal veins became negative had passed at once to the
heart.

6**- ¥ %

The Amniotic Fluid a Means of Fostal Nutrition.

Ahlfeld (Zeitschriftfiir Gcburtthulfc, Band 14, Heft 2) concludes, from the

examination of the meconium, that the foetus swallows considerable quanti-

>f the amniotic fluid. This is a physiological process ; he has found the

amniotic fluid albuminous in several cases, ranging from twenty to fifty per

cent, albumin. His tests were nitric acid and heat.

includes that the albumin of the amniotic fluid is nutriment for the
foetus, and by an elastic bag applied over the mother's abdomen at the loca-
tion of the child's back, he demonstrated movements of the child's thorax in
the uterus, which he considered motions of deglutition.

The Microorganisms in the Genital Canal of the
Healthy Female.

Winter {ZeiUchrift fiir GeburUhulfe, Band 14, Heft 2) reports experiments
undertaken at the suggestion of Schroder, to determine what microorganisms
are present in the various portions of the female genital canal.

He concludes that the normal Fallopian tube contains no microorganisms.
The normal uterine cavity contains no germs ; in half the uteri examined
they were present at the internal os. In the secretion of the cervix were

320 PROGRESS OF MEDICAL SCIENCE.

found abundant microorganisms, which increase during pregnancy ; bacilli
also develop. The vagina always contained abundant germs. The boundary
for germs is the internal os uteri. These microorganisms were found to be
pathogenic, but not possessing the virulence commonly characterizing them.

Winter urges the practical conclusions regarding the disinfection of the
vagina and cervix before operations which follow from these facts. He re-
gards the germs always present in the external portion of the genital canal
as capable of becoming virulent when infected from without; in that case
infection of the portion of the tract otherwise free would occur, and auto-
infection result.

The Prevention of Ophthalmia Neonatorum.

Ahlfeld, in the clinic at Marburg, has not had a case of pronounced
ophthalmia neonatorum for three and one-half years, and no suppurating con-
junctivitis for one and one-quarter years. This immunity he ascribes to the
use of an antiseptic douche before labor; cleansing the child's eyelids as
soon as the head is born; keeping the child's face as much as possible from
the fluids in the vagina; and precautions in bathing the child. The face and
head are never bathed in the water which cleanses the body ; the eyes are
bathed with clean water, by means of cotton.

Ahlfeld has no explanation for the fact that children seldom acquire the
disease after the first week of life. — Zeitschrift fiir Geburtshulfe, Band 14,
Heft 2.

The Influence of Drugs Taken by Nurses upon Nurslings.

1'i.iiMNG (Medici/ /'/•'.->•, Muy 9, 1888) has made investigations upon this
subject, as follows:

Soluble substances pass from the blood into the milk. Sodium salicylate
became dangerous to an infant after its nurse had taken forty-five grains;
iodide of potassium may be given in daily doses of three grains without
injury ; it was found in the milk twenty-four hours after the nurse ceased to
take it. Potassium ferrocyanide does not pass readily into the milk.

Iodoform, even when applied externally to the mother, passes very readily
into the blood, and affects the child more powerfully than when it is applied
to lesions upon the child. Mercurials given to the mother do not affect the
child readily.

Regarding narcotics, twenty-five drops of tincture of opium (German Phar.)
did not affect the child; he concludes that from one-tenth to three-tenths of
a grain of morphia may be given at a dose with safety t<> the child ; from
twenty to forty grains of chloral may be likewise given. If the breast was
withheld for one and a half or two hours after these doses no effects on the
child were observed. Atropia affects the child very readily and powerfully.

Fchling experimented with citric acid, mineral acids and vinegar, finding
that their use does not affect the child; the normal alkalinity of the milk
remains undisturbed. No restriction in this direction should be put on
mothers' diet.

As to the influence of fever upon the milk, the septic fevers counter-indi-
cate nursing, because the milk ducts and secretion are infected with micro-

GYNECOLOGY. 321

cocci. The child should be at once taken from the breast in these cases. In
non-septic fevers the child should nurse so long as the secretion remains, and
simple means should be used to abate the mother's fever.

GYNECOLOGY.

UNDER THE CHARGE OF

HENRY C. COE, M.D., M.R.C.S.,

OF NSW YORK.

The Treatment of Retroflexion.

An interesting discussion on this subject occurred at the recent meeting of
the German Gynecology Society, at Halle ( Centralblntt fur Gynakologie, June
16, 1888). It followed a paper by Skutsch, who advocated the more intelli-
gent use of pessaries, even in cases in which the uterus could not be entirely
replaced in consequence of firm adhesions ; the latter might be stretched by
gradual pressure and systematic massage. Cord-like adhesions were best
stretched by bimanual palpation, while in the case of broad bands or exten-
sive parametric exudates, Brandt's method of bimanual massage was valuable.
If the movements of the uterus were limited, but the organ was not fixed, it
should be replaced and a pessary introduced. In order to carry out this treat-
ment successfully, it was necessary to recognize by careful vaginal and rectal
examinations the exact anatomical condition. Of 205 cases of retroflexion
treated in Schultze's clinic, 182 were decidedly benefited by pessaries; in 15
cases of fixation, the adhesions were stretched by pressure and massage, so that
the uterus could be replaced, while in 19 they were separated according to
Schultze's method.

In cases of abnormal shortening of the anterior vaginal wall, the tension
might be relieved by making transverse incisions, and uniting them in a line
parallel with the axis of the vagina. Skutsch thought that in obstinate cases
of retroflexion laparotomy offered the only certain prospect of cure, but it was
to be regarded as a last resort. Sanger said that he preferred ventro-fixation to
Alexander's operation. Fritsch thought that pessaries were invaluable if
rightly used ; it was easier to perform a laparotomy than to treat a case of
retroflexion successfully Winckel agreed with the last speaker; while in
America he had observed the bad effects of Alexander's operation. Schultze
confirmed the experience of Fritsch, and added that he had never seen com-
plications disappear by replacing the displaced uterus.

Cauterization Versus Curetting in the Treatment of
Endometritis.

A recent discussion on this question before the Paris Obstetrical and Gyne-
cological Society {Bull, et Memoiret, June, 1888) was of interest by reason of
the expression of their views by several prominent French gynecologists.

322 PROGRESS OF MEDICAL SCIENCE.

Pajot stated that he has practised cauterization of the uterine cavity for
endometritis for nearly forty years, and had never had a fatal result follow
the treatment ; he had noted only four cases of perimetritis which could be
referred to the application. This freedom from accidents he attributed to
the strict observance of antiseptic precautions.

Charpentier preferred curetting to the use of the porte-caustique, because
of the greater rapidity of the cure, and the absence of pain and inflammatory
complications.

Doleris warmly defended the curette by the use of which all the diseased
tissue was removed and could be examined microscopically, while there was
no danger from cicatricial contraction of the canal which sometimes resulted
from caustics. There was certainly more risk of setting up periuterine in-
flammation when cauterization was practised. If caustics were applied, it
should be done after the diseased tissue had been removed.

[It will appear almost amusing to the American reader that M. Doleris,
whom we recognize as the most progressive French gynecologist, should find
it necessary to champion the cause of the curette as opposed to a method of
treatment which we long ago rejected as barbarious and unscientific. — Ed.].

The Extra-peritoneal Method of Treating the Stump after
Supravaginal Amputation.

Prof. Carl Braun (Wiener med. Wochenschri/t, 1887, Nos. 22-25) reports
thirty-eight cases of hystero-myomotomy in which the stump was treated
thus, the mortality being only 15.5 per cent. The pedicle was dropped back
in two other cases, which terminated fatally. The writer prefers the former
method, which has won favor among Vienna gynecologists by reason of the
good results which have attended its application to Porro's operation.

Second Laparotomy in the Same Patient.

Martin (Centra //>/«/( /iir Gynakologie, June 23, 1888) has performed lapa-
rotomy upon twenty-two patients for the second time, exclusive of cases of
secondary laparotomy within ten days after the primary section. In ten
cases the operation was for disease of the remaining ovary, in seven, for
salpingitis resulting from acute gonorrheal infection, or from a recurrence
Of the tmuble for which the other tube was removed. In four instances
uterine fibro-myomata had developed after the first operation. It was noted
at the time of the second laparotomy that even when the patient had recover. .1
from the former one without any evidences of peritonitis, it was the rule to
find the intestines adherent to the abdominal wall and to one another. For
this reason, Martin always made liis second incision at the side of the old
cicatrix. In order to avoid the necessity of a subsequent operation, it was
:>le to remove, if possible, all diseased tissues the first time. Although
he met with great difficulties in secondary laparotomies, the writer lost
only one patient from m ipcfai and two from collapse. If the old cicatrix
was much ttretehed he thought it best to excise it entirely, in order to avoid
subsequent hernia.

GYNECOLOGY. 323

Preliminary Operation before Opening Cystic Tumors.

Keil (/./., June 30, 1888) advocates this measure, which was first employed
by Volkmann. Its object is to avoid the danger consequent upon the rupture
of a firmly adherent purulent sac during the attempts to extirpate it. An
incision is made in the inguinal region, the cyst is exposed and its wall is
iied to the edge of the wound ; the latter is left open and is packed with
iodoform gauze. At the end of a week the dressing is removed, and the cyst
is found to be adherent to the abdominal wall ; it is then incised and drained*
and is allowed to close by granulation.

A M mikication of Alexander's Operation.

Casati (Raccoglitore med., 1887, Nos. 5-8) in shortening the round liga-
ments makes a single transverse incision through the skin, somewhat curved,
with its concavity upward ; this unites the two external rings. Both round
ligaments are then drawn out and the redundant portions are excised.
The proximal end of each cord is next stitched to the distal end of the oppo-
site one, so that they form a cross ; the latter is united to the subjacent cellular
tissue by a continuous suture of catgut, after which the wound in the integu-
ment is closed with silk. The uterus is supported by means of vaginal
tampons.

Vaginal Cysts.

Takahasi (Deutsche medicinische Wochemehrift, June 7, 1888) has investi-
gated the vexed question of the origin of vaginal cysts, and describes the
microscopical appearances observed in six specimens. Unlike Hening and
other observers, he was unable to find any true glands in the sections exam-
ined, although in two cases he noted the presence of follicles, which he re-
garded as of inflammatory origin. He inferred that the epithelium lining
the cysts was derived from that of the vaginal mucosa. The deep situation of
the cysts within the muscular layer, and even between the fibres, showed that
they could hardly arise, as some writers claimed, from crypts or folds in the
mucous membrane. On the other hand, Takahasi found circumscribed col-
lections of cells in the vaginal mucosa, in the centre of which were evidences
of commencing cyst formation. The fact that cysts were situated with nearly
equal frequency on the anterior and posterior walls of the vagina was, in his
opinion, an argument against the theory of their frequent development from
the ducts of the Wolffian bodies. In short, vaginal cysts in the same patient
may have an entirely different origin, so that it is impossible to refer them all
to a common source.

Colpitis Emphysematosa.

Under this term Zweifel ( Archiv fur Qynakologie, Bd. xxxii. Heft 1) de-
scribes a condition to which Winckel gave the name '' cystic hyperplasia" of
the vagina. Contrary to the opinions of Klebs, Ruge and others, Zweifel
claims that air-cysts originate in the glands, even though many of the cysts
have no epithelial lining; the disappearance of the latter may be due to long-
continued pressure. The fact that the gas has been found diffused throughout
the interstitial spaces may have led the authors mentioned to overlook their

324 PROGRESS OF MEDICAL SCIENCE.

glandular origin. In the cases observed by the writer the fact that the
vaginal secretion contained many air-bubbles, as well as its offensive odor,
led to the inference that the gas in the cysts, as well as in the vagina, was the
result of decomposition, while the presence of trimethylamine in both the
cysts and the vaginal secretion caused him to believe that the former ruptured
in consequence of the expansion of this gas when heated. From repeated
observations he found that trimethylamine was sometimes present in the
genital secretions of healthy pregnant women.

Dilatation of the Urethra to Relieve Retention of Urine
following Delivery.

Schatz has called attention to a simple method of relieving retention,
which he considers preferable to the ordinary practice of repeatedly using a
catheter until the patient developed cystitis. He employed an instrument
like a glove-stretcher, which was introduced into the bladder and opened,
the sphincter vesica? being dilated so that the tip of the little finger could
be passed through it. The pain was slight and ceased immediately after
the operation. There might be slight hemorrhage. A second dilatation
was seldom necessary, as the urine was passed the next time spontaneously.
Schatz believed that the practice would become general, since it was so much
less harmful than the frequent use of catheters.

He was unable to give a satisfactory explanation of the modus operandi of
the operation, but he was led to test it by comparing the physiology of vesical
with that of uterine contraction. In normal urination, the detrusor was not
to be regarded as the antagonist of the sphincter vesicae, but the former could,
however, relax the sphincter. In most women the bladder was actually in
diastole during micturition, so that it was necessary to infer the presence of
some other mechanism for relaxing the sphincter, either a passive relaxation
of the latter muscle, or active contraction of its antagonists which were in-
serted somewhere on the pubic bones. If these muscles were torn during
parturition, they might be powerless to relax the sphincter. Passive relaxation
of the sphincter itself would naturally take place more rapidly if, after being
swollen or irritated, it was rendered more pliant by stretching. Dilatation
was also applicable to retention in the non-puerperal woman, but it was
more uncertain in its results; it was especially applicable to retention after
operations. — Cknimlhlnit filr Oi/n., June 16, 1888.

MEDICAL JURISPRUDENCE.

IM'I'.i: 111!-. CHARGE OF

MATTHEW HAY, M.D.,

PRornaoR or mrdical jurirpruokncr, unitcrsitt or abkrdkrn.

On Medical Responsibility.

L. Reuss (Annal. (Thyg.publ., ser. 3. t. xix. pp. 528-550) discusses, under
the above title, the case of Dr. Flocken, of Strassburg, who, along with a

MEDICAL JURISPRUDENCE. 325

druggist and his two assistants, was charged with the contravention of certain
articles of the German penal code, which render it criminal for any one who,
in the practice of his profession or trade, causes the death of a person by
acting to give such particular attention to his studies as, by his profession,
he ought to do.

It appears that Dr. Flocken, who occupies a highly respectable position,
was, toward the close of last year, called to attend an innkeeper, Mathias,
suffering from arthritic pains, and prescribed a liniment and a mixture. Two
spoonfuls of this mixture were taken by the patient within two hours, and
shortly afterward he suffered from vomiting and diarrhoea. Nevertheless, a
third spoonful was taken, and the vomiting and diarrhoea increased, accom-
panied by irritation of the throat, constriction of the belly and insatiable
thirst. The doctor was again summoned and came. He asked for the bottle
which contained the mixture, washed it out with warm water and carefully
scraped off the label. He then placed some iodide of potassium in it, added
water and ordered the patient to take the new mixture at certain intervals.
After three or four doses the vomiting ceased, but the diarrhoea continued.
The doctor revisited the patient and tried other remedies to arrest the diar-
rhoea, but without success. The patient now became very feeble, complained
of a suffocative feeling and abdominal pain, with cold extremities, and died
thirty-six hours from the time he took the first dose of medicine prescribed
by the doctor. The doctor then asked for his first prescription and took it
away with him, and afterward certified the cause of death to have been endo-
carditis following upon an attack of articular rheumatism.

On the following day, an anonymous letter was received by the police
authorities, directing their attention to the suspicious character of the inn-
keeper's death. Dr. Flocken was at once interrogated by the authorities
and stated that his first prescription consisted of a little digitalis mixed with
either salicylic acid or tincture of colchicum, or possibly with salicylate of
lithium. On the following day he confessed to having made a mistake and
then remembered that he prescribed digitalis and tincture of rhubarb. As
the prescription had been dispensed by a druggist, Greiner, his register of
prescriptions was searched, and one by Dr. Flocken was found, corresponding
to that under discussion. It contained infusion of digitalis, salicylate of
lithium, extract of rhubarb and syrup, all in ordinary doses; but the register
examined was a new one and seemed to have been begun only two days before
Dr. Flocken's prescription was entered. Further investigation showed that
the register was bought three days after the day of entry of the doctor's pre-
scription. The exhumation of the innkeeper's body was then determined on
and was carried out about three weeks after the death. The autopsy revealed
no particular cause of death. The mucous membrane of the stomach and
intestines was much congested and was covered with several small ecchy-
moses. All the other viscera were healthy. No poison was found.

Meanwhile, information reached the police authorities of the death of
another person, a barman, Herter, under similar circumstances, and also the
patient of Dr. Flocken. Herter became ill, suffering also from arthritic
pains, on the same day as Mathias, and was on that day prescribed for by
the doctor, who ordered a liniment and mixture as before. The prescrip-
tions were also dispensed by Greiner. The same results followed the admin-

326 PROGRESS OF MEDICAL SCIENCE.

istration of the mixture — vomiting and diarrhoea. The doctor, at his next
visit, asked for the bottle, washed it out, scraped off the label, as in the other
case, and refilled it with a solution of morphine. The new medicine stopped
the vomiting, but the diarrhoea continued, and the patient died on the fourth
day after he had begun to take the prescribed medicine. Professor Wieger
was called in as a consultant before the patient's death and was told by Dr.
Flocken that the patient had been ordered some colchicum ; but the professor
attached no importance to this and attributed the illness and death to a fatty
heart and nephritis, preceded by diphtheria, diarrhoea and a gouty attack.
Dr. Flocken certified the cause of death to be paralysis of the heart, following
upon enteritis, with nephritis and pericarditis. Herter's body was also
exhumed after about three weeks. The kidneys were much congested, the
heart and liver somewhat fatty and the large intestine showed traces of
diarrhoea, without much alteration of the mucous membrane. In this case
the registered copy of the prescription for the mixture showed that it con-
tained tincture of colchicum, salicylate of sodium and extract of juniper, all
in ordinary doses.

Finally, Dr. Flocken, Greiner and his two assistants were arrested ; when the
druggist confessed that he had, at Flocken's request, altered the register of
the prescriptions and for that purpose had purchased the new register already
alluded to. The original prescriptions had each contained extract of colchium,
but in such dose as would be suitable to the tincture of colchium. Dr.
Flocken now admitted this; but to clear the conscience of the tribunal a
large number of skilled witnesses were brought forward at the trial, includ-
ing men of such eminence as Fliickiger, Schmiedeberg, von Mering, Huse-
mann and Wieger. It was contended, on behalf of Dr. Flocken, that the dose
of the extract prescribed was not poisonous; and that, even if it were, the
patients had had the poisonous action neutralized by subsequent treatment
and that they had died from natural causes. Schmiedeberg and von Bferittg
testified that the dose of the extract prescribed — viz., about 0.2 gramme (3
grains] in each spoonful— was equivalent to about 15 or 20 grammes (225 to
300 grains) of the tincture, three spoonfuls, or the quantity taken by each
patient, being equal to 45 to 60 grammes (675 to 900 grains), and that such a
quantity was undoubtedly poisonous, the maximum medicinal dose being, in
their opinion, 6 grammei (90 grains) daily. Husemann, on the contrary,
maintained that theextrad is not so much more poisonous than the tincture;
that a maximum medicinal dose is, at best, a mere hypothesis; and that
although the two deaths might have been due to colchicum, yd they were
more probably caused by disease. Wieger asserted that Herter had died of
a heart affection. The tribunal found Flocken, Qreiner and one of the
-ants guilty and sentenced the first to ten months imprisonment and the

others to live days and two months respectively.

l, the author of the present communication, traverses the conclusions
of the tribunal and, of certain of the medical witnesses, and, although admit-
ting that the dose of colchicum prescribed may have been a poisonous one, he
OOntendl that Flocken exhibited no criminal neglect— that he had simply made
the unfortunate slip of writing extract instead of tincture. He denies that
tlir tribunal received clear evidence as to the deaths being due to colchicum
and not to natural causes. It appears, however, to the writer of the abstract

MEDICAL JURISPRUDENCE. 327

that there can be little, if any, doubt as to colchicum being the cause of death
in both cases.

Water ix the Stomach as a Sign of Death by Drowning.

Obolonsky, of Charkow, Russia, reports in the Viertelj. f. gericktl. Med.
N F. Bd. xlviii. S. 348-352, 1888) the results of eighteen experiments with
the dead bodies of infants, two weeks to two months old, in which he placed
the bodies in a large vessel of colored water, sinking them by means of
attached weights, and observed by dissection afterward whether water had
penetrated into the stomach. The bodies remained in the water for twenty-
four hours to three days. No water was found to have entered the stomach
during twenty-four hours' submersion ; but in five of the bodies submerged
for three days, water had entered the stomach. In three of these, a notably
large quantity of water was found ; in the remaining two, a small quantity.

M experiments confirm the conclusions of Liman and Hofmann and
are opposed to the earlier, and in some countries still current, teaching of
medical jurists. They show that water in the stomach (swallowed from the
water in which the person was drowned) does not afford indubitable proof of
death by drowning since the water may enter the stomach after death.

Case of Bestiality. — -— -

A singular case of this kind has been reported to the Soci6t6 de Medecine
legale de France by a physician of Orleans {Annal. J'hyj puN , -ftp nf rio, r
Til) pp fifUfiflft who desires to conceal his name. The physician was called
to a male domestic servant, aged eighteen or nineteen years, who was suffer-
ing from a large wound in the anus, which had bled profusely. The wound
was about two inches long and was of the nature of a large rupture of one
side of the anus. After much hesitation the boy confessed that for some time
before he had frequently permitted a large, strong spaniel to have connection
with him. The connection had been, until the last occasion, unattended by
injury. On this occasion, however, the boy having been called in the middle
of the act and afraid of being surprised by a visit from his master, endeavored
to detach himself as speedily as possible from the dog. This was rendered
difficult by the non collapse of the large swelling toward the base of the
dog's penis, which was grasped within the anus. The boy, however, in spite
of the cries of the dog and his own suffering, contrived finally to separate
himself forcibly from the dog, but not without producing the large rupture
of the anus referred to.

This case is interesting in view of the statement made by Bouley and
Brouardel and others that connection of dogs with men is highly improbable.

■ HOLIC POISONIN'i.

C. Seydel, of Konigsberg ( Viertelj. f. gerichtl. JftdL, N. F., Bd. xlviii. S.
430-449, 1888), presents a study of the literature of this subject, accompanied
by several operations and experiments (on rabbits) of his own, with the
object of ascertaining the characteristic pathological changes in death from

328 PROGRESS OF MEDICAL SCIENCE.

alcoholic poisoning, acute and chronic. He enters into a lengthy criticism of
Formad's results, which, for the most part, Seydel is not able to confirm.

The changes in the volume and form of the kidneys (pig-backed) which
Formad described as diagnostic of acute alcoholic poisoning Seydel has not
met with either in man or in rabbits. He attaches importance, however, to
the cloudy condition of the epithelium of the tubules of the kidneys, also
mentioned by Formad. It may be expected in cases of death from repeated
alcoholic excesses. The same is true of albuminuria. The kidneys are
usually distended with dark fluid blood after death from alcoholic poisoning,
and the blood of the body generally is of a dark color.

An Epidemic of Lead-poisoning.

Bertrand and Ogier (Annal. d'hyg. publ., 3e serie, t. xix. pp. 68-75) give
the results of an investigation of an epidemic of lead-poisoning which broke
out simultaneously in three separate communes in the neighborhood of
Roanne, and afterward extended itself to other adjoining communes, more
than one hundred persons, of different ages, being affected, and these belong-
ing to the poorer classes chiefly. It was not attributable to the water-supply,
as the water used by the various affected persons was taken from widely
separate sources ; nor was it due to the use of lead-glazed pottery or lead-
plated utensils. Everything pointed to some article of daily diet being the
carrier of the lead ; and the author suspected the flour. Subsequent inquiry
showed that the flour in every case had been ground in a particular mill.
Chemical examination of various samples of flour from this mill revealed the
constant presence of lead in small quantity.

It was at first supposed that the lead had been obtained, as in some pre-
viously reported cases, from the lead sometimes used to fill fissures in the
mill-stones, but the stones of this particular mill were found to have been
repaired with a cement which contained no lead. The source of the lead
was afterward discovered to be lead-plated cups, fixed to a revolving endless
belt, which were employed to raise the flour to an upper part of the mill
When these were replaced by tinned-iron cups, the lead entirely disappeared
as also did the lead-poisoning.

Chronic Illness from Inhalation of Hydrocyanic Acid.

ALOYS MARTIN (Ein I'nll von chronischem Sirchthmn, hervorgcrn/rn dwrch
Eintithmitng von Blausaure, Niirnberg, 1888) describes the ease of a young
woman, who, while engaged for a week silvering and polishing metallie an-
tiquities with a double compound of cyanide of silver and potassium, became
ill, with difficult breathing, headache, loss of appetite, irritation of throat,
cough, much thirst and great weakness, so that she was compelled to take to
bed. Prom the '11 of March, 1886, onward, she developed a chronic illness,
Which about the middle of October following was characterised by feeble
heart, distinct ataxy, impaired sense of taste, a shuffling gait, a well-marked
diminution of muscular power and anemia. Electrical treatment was then
began, and the patient steadily improved, but was not quite restored to
health even by the end of the year 1887. Martin ascribes the poisonous
s to the inhalation of prussic acid.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES,

OCTOBER, 188 8.

THKEE SU< CE8SFUL CASES OF CEREBRAL SURGERY.

INCLUMNG (1) THE REMOVAL OF A LARGE INTRACRANIAL FIBROMA J

(2) EXSECTION OF I>AMA(iED BRAIN TISSUE; AND (3) EXSECTION

OF THE CEREBRAL CENTRE FOR THE LEFT HAND;

WITH REMARKS ON THE GENERAL TECHNIQUE OF SUCH OPERATIONS.1

By W. W. Keen. M.D.,

profrmor or scrgeby in the woman's judical college or Pennsylvania ; si-roeon to st mart's,

ST. AGNES'S AND THE WOMAN'S HOSPITALS, ETC.

Case I. Large tumor in the cerebrum probably arising from an injury

at three years of age; epilepsy and hemiplegia at twenty-three ; tumor re-

h> mia cerebri ; recovery ; probable cure of epilepsy.

Seal to me in May, 1887, by Dr. M. L. Davis, of Lancaster, Pa., with
the following history.

'• T. D., aged twenty-six, carriage-maker, married at twenty-three, has
one child in good health ; father died at twenty-seven from an injury to
the spine ; mother and maternal grandmother (aged eighty-three) living
and in good health ; the other three grandparents died at fifty- seven,
seventy and sixty, the last of consumption.

the age of three he fell out of a window, a distance of several feet,
striking his head upon some bricks. His mother says there was no cut,
but his forehead was indented. He lay motionless for a long time as if
he were dead, and remained comatose for an hour. His head became
swollen and blue. Dr. John L. Atleesaw him the next morning and, as
the child was moderately bright, thought he was merelv stunned, as
there was no evidence of injury except the swelling. The recovery
from the injury was slow but apparently complete. The indentation
was on the front part of the head, but the mother does not remember
clearly on which side. The patient says his mother told him it was on
the Ken side.

> Read before the American Surgical Association September 18, 1888.

YOU 96, HO. 4. — OCTOBER, 1888.

330 KEEN, CEREBRAL SURGERY.

"At five years of age a discharge from the right ear followed an attack
of measles. This discharge has continued at intervals ever since, and
has impaired his hearing. It is at times offensive, although accompanied
by but slight pain. In August, 1886, the left ear became partially deaf.
During his boyhood he was considered dull, was very forgetful and impul-
sive though not quarrelsome ; he complained considerably of headache ;
no history of syphilis can be obtained and there is no visible manifesta-
tion of it after the most careful examination. His general health was
food, excepting the frontal headaches, which were moderately severe,
n the autumn of 1884, he became ill with neuralgic pains and was "all
broken up." These symptoms gradually increased until February,
1885, when he was seized with violent epileptic attacks followed by
intense pain in the head which lasted several days. These fits occurred
once or twice a week, and the attacks of pain in the head increased in
violence and duration. By the end of April the right arm became
paralyzed, and the right leg, and the right side of the face, in the order
named, the paralysis making gradual progress.

" My first visit was made on June 8, 1885. While hitching my horse,
I heard him screaming with neuralgic pain. The pain was located on
the left side of the head, and started about the supraorbital ridge, dart-
ing back to the occiput, but was more intense at the middle of the left
side of the head. Inspection disclosed a small scar at this point.
Pressure increased the pain. The entire right side of the face was
paralyzed ; both motion and sensation being affected, though motion had
suffered more than sensation. The right pupil was largely dilated and
did not respond to light; the left one was normal and responsive.
The sight of the left eye was good, but whether perfect or not I could
not determine. The vision of the right eye is imperfect ; aphasia is a
prominent symptom. He made marked efforts to converse, but could
not; the pulse was 60 and irregular; respiration 16; tongue heavily
coated ; obstinate constipation ; anorexia ; insomnia ; no fever.

"Diagnosis. — Pressure upon the anterior lobe of the left hemisphere
involving the third convolution, extending backward, from exostosis,
tumor or possibly only thickening of the dura mater ; syphilis excluded.
" Treatment. — Iodide of potassium and arseuic with laxatives.
"The pain began to diminish and at the end of three weeks he was
nearly free. Arsenic was suspended by July 1, 1885. Paralysis began
to improve in the leg and in the arm. Aphasia was the last to improve.
so that when he had regained the use of the leg and arm and could
come to my office (a mile distant), he would bring pencil and paper and
write any questions he desired to ask. The questions were, however,
much mixed. About this time his eyesight began to fail until August,
1885, when he became totally blind, first in the right eye and later in
the left. At the end of two months his left eve gradually improve. 1
so that he could again walk in the streets. The right eye remained
blind for several months, when suddenly the sight returned in it. re
mainetl for a few hours and left as quickly as it came. This phenome-
non has since occurred frequently, not only in the right eye but also in
the left, He was annoyed, also, very much by flashes of light and mi>t
before the eyes, accompanied by vertigo and constipation.
"The epileptic fits continued with diminished violence and frequency

until November, 188(5. since which time he has been exempt. His urine

has been frequently examined, bal there was found neither albumin.

KEEN. CEREBRAL SURGERY. 331

rtfl nor sugar. In the fall of 1886 he was at Jefferson Hospital, but
returned after three weeks. His mental condition has been considerably
affected ; his judgment is not good ; memory fair; general mental powers
■low ; at times peevish and fretful."

May 30, 1887. ftm • ni condition. Headaches moderately severe, gener-
ally lasting from half an hour to several hours, and occurring from two
or three in a week to one in several weeks. His speech is hesitating and
slow and he has a feeling as of being dazed. He is very anxious to have
an operation done if it holds out the slightest possible chance of relief.
When he has spasms " hot air seems to rise from the stomach to the nose ;"
the eyes become dim and twitch toward the right followed quickly by the
head, which is turned in the same direction. During this time he is
mostly conscious and feels as if smothered ; unconsciousness soon follows.
As soon as the " hot air" is felt the right hand closes tightly, the forefinger
first then the thumb. He cannot tell whether the wrist, shoulder, and
elbow are flexed in succession. The face also is affected (whether one
side or both he does not know ) and turns to the left, so that it seems " as
if he were going to be turned entirely round to the left." These attacks
last from five to ten minutes. Sometimes he has minor attacks with the
same symptoms moderated without loss of consciousness. He has a good
movement of the bowels every day ; appetite ravenous ; for four or five
weeks has had night sweats almost every night, especially on the legs ;
bus lost flesh since March 1st ; his usual weight is 135 pounds, present
weight 122 pounds. The gait would not now show any paralysis ; his
hand squeeze is about equal ; the leg-thrust of equal force, as judged by
tance to my hand; the face is not paralyzed; the right ear has a
slight discharge, but is the better hearing ear of the two ; his deafness
for conversation, however, is only moderate ; the right pupil is slightly
larger than the left. The right eye deviates slightly upward and out-
ward. An examination of the head shows a small scar a quarter of an
inch long, three and three-quarters inches above the middle of the zygoma
and one and five-eighths of an inch in front of the bi-auricular line. The
skull feels slightly irregular as if the bone had been injured ; no marked
depression ; not now tender or painful, nor is there any sensation located
at this point preceding the fits. The urine is rather highly colored and
■tightly clouded, the specific gravity 1023, no albumin, no sugar, a few
crystals of uric acid ; normal mucus.

Jtme 7, 1887. While in the hospital he had six fits to-day. Dr.

Ian saw the fourth from the beginning. The eyes were staring,

with the whites turned up, the eyelids moved rapidly up and down; the

right pupil was larger than the left ; the head was turned far to the

right and the mouth drawn in the same direction ; the four limbs were

flexed throughout. He was lying on the left side, with the feet turned

to the left, and rigid. This condition soon passed into marked convul-

efforts. The attack lasted two minutes. The face was normal in

color at first but soon became very blue. There was no frothing at the

mouth. A few days later Dr. Charles A. Oliver saw him in the convul-

stage of an attack which was described as follows, together with a

careful ophthalmic examination :

" At the request of Dr. Keen I examined T. D., and obtained the
following results :l The pupil of the right eye was four by five mm. in

This merely constitutes a rimamiot sufficient fulness to render the case complete, referring the
di.-iuv-i.n iu tmtmm (in connection with other cues observed with Dr. Keen) for a separate commu-
nicat:

332 KEEN, CEREBRAL SURGERY.

size upon exposure to broad, diffuse daylight, whilst the pupil of the left
eye was three by four mm. in size upon the same exposure. Both irides
responded separately to light stimulus and accommodation, the right
pupil becoming larger in all directions after a second's continuance of
stimulation to what it had been brought by the first impulse of light.
The right iris was slightly the more sluggish, each responding only when
the stimulus was placed in small areas to the right of the eyes. The test
for accommodation, which was made by approximating the finger and
having the patient steadily gaze at it, taking care to keep it at the point
of greatest visual acuity in the visual fields, showed that the irides were
exceedingly sluggish. Both cornea? were seemingly equally sensitive, and
a difference of six-tenths of a degree F. in the temperatures of the two
lower culs-de-sac could be differentiated. (Right = 97.7° F., and Left
= 97.1° F.) In a state of rest, fixation was accomplished with the left
eye, the right being turned up and out. Careful examination showed
that this condition was caused by a paresis of the right internus coex-
istent with paresis of the left inferior and superior recti ; all of the other
attached external and internal muscles being intact. In addition, there
was a paresis of the inferior fibres of the orbicularis on both sides, more
marked on the left; the left lower eyelid being partially raised by the
corresponding face muscles. Vision with the right eye was reduced to
the counting of fingers at six inches, about four degrees to the outside,
whilst vision with the left eye, which was also eccentric, was reduced to
the counting of fingers at thirteen inches, about six degrees to the inside.
Fields of vision gave the following results: left-sided homonymous hemi-
anopsia superadded to large central scotomata; leaving two irregularlv
contracted right-sided fields in which nothing but form could be dis-
cerned.

" The ophthalmoscope showed in each eye a few faint vitreous opacities
— almost complete post-neuritic atrophy with greatly diminished retinal
circulation (the arteries being reduced to mere threads), much more
marked on the left side; both choroids woolly and granular ; whilst in
the right retina there was a small isolated brilliant cholesterin crystal.
Both disks gave decided characteristic appearances of previous choking.

"Five days later the patient was seen in the convulsive stage of an
epileptoid attack. He had been complaining of frontal headache, accom-
panied by ' bad taste,' followed by vomiting. When first seen there won
a series of irregular clonic contractions, which were marked in both Lower
and upper extremities of the right side and trunk, the head being turned
toward the right. The mouth was drawn away from the left side. The
righl eye was lixed toward the upper temporal side, whilst the left devi-
ated almost directly inward. I hiring this deviation a slight horizontal
nystagmus developed itself, which, as the general clonicism grew less and
less, rapidly diminished, the excursions becoming greater in length and
less frequent in action, with a steadily increasing tendency to fall into
the ordinary state of rest, until in four minutes from the time when first
seen, the oscillations had ceased altogether. During the nystagmic
action the axis of the right eye was directed up and out, and the globe
ighl twist downward upon its return internal movement. At

time of the convulsive seizure the righl pupil was dilated to six by

D mm. in rice, whilst the left pupil was enlarged to hut four by five
mm.; each pupillary area preserved its original long axis. The lower

Kds drooped during the elonie state, whilst the upper lids became con-

KEEN, CEREBRAL SURGERY.

333

tractod, giving the eyes a staring appearance. Throughout this time
the skin of the litis ami the conjunctival mucous membranes seemed to

334 KEEN, CEREBRAL SURGERY.

be sensitive to touch and pain. It was now noticed that the patient
profusely sweated upon both sides, and that there was equal thumping
pulsation of the external carotids. At the moment of cessation of the
nystagmic motion, and without the patient being spoken to, or aroused
in any way, the right fissure closed and the left upper lid began grad-
ually to fall over the eyeball, the pupil contracting to two by three
mm. on the left side and three by four mm. on the right. At this time
both irides were mobile to strong light stimulus thrown from the areas
of the retained fields ; the iris of the right eye giving the lesser reaction.
Upon the patient being aroused (he, from appearances, never having
entirely lost consciousness) the upper lids elevated, the right eye fixed
to my position upon his left side, the left eye turned out and the pupils
dilated to normal ; the eyes, head, trunk and extremities still remaining
in the same positions as during the convulsions. By still further con-
centrating the attention — i. e., by talking to him in a loud and sharp
tone of voice and causing him, at the same time, to gaze into the broad,
diffuse daylight, his pupils contracted again to the sizes noted at the time
of the cessation of the nystagmus, returning to their normal relative
areas a moment later. Urine was examined at the time, giving negative
results."

The patient was also examined by Drs. S. Weir Mitchell, Morris J.
Lewis and George C. Harlan. The latter gives the following result of
the examination of his ears. His examination of the eyes coincided
with that of Dr. Oliver.

"A. D., partially deaf since early childhood after an attack of measles,
still occasional discharge. H. = watch at four inches ; lower posterior
quadrant membrane destroyed, the remainder much thickened. The
drum suppurating slightly.

"A. S., deafness came on suddenly (?) one year after a convulsion in
'consequence of a dose of medicine'; watch not heard on contact;
tuning-fork not heard at all through air, but normal by bone conduc-
tion through mastoid. Membrane thickened and much contracted.
Eustachian tubes apparently not patulous. Deafness evidently due to
local changes, not to any cerebral complications."

For reasons given later under head of remarks, it was decided not to
do any operation at present, but if, in the fall, after careful treatment
under I>r. Davis, especially with the iodides, he should not be better
and still desire an operation, that I should open his head. He returned

h e the middle of June. He had an epileptic fit on June 24th, July

26th and August 13th.

In the fall of 1887 I received several letters written by himself, as
well M one f'min Dr. Davis, desiring an operation. The patient himself
- quite argent, and accordingly came to the city to St. Mary's Hospi-
tal in Decern]

8, 1887. The scar finally settled upon as that resulting from his
Edenl at three years of age (though his mother had stated his scalp
was not cut), was a quarter inch long and half an inch above and in
■ t of the superior stephanion, two and s quarter inches to the left
of the middle line, and three inches behind the external angular pro-
cess. It was now tender l.oth t<> pressure and to a slight blow. The
perature over the scar on this side of the head was 95.5° F., and
in a oorrespondinp position on the right side i)4.4° F. Swayantero-

sinistral half an inch each way. Dynamometer, right hand 30°, and

KEEN, CEREBRAL SURGERY. 385

left 35D. Knee-jerk, left, normal ; right, subnormal. Reinforcements
normal on both sides. Tactile sensibility in both hands normal.

14th. Temperature over the scar 95.5° F; right side, corresponding
point, 96° F. Urine, specific gravity 1028, no albumin, no sugar.

An attempt was made to see if the scar was the site of the
highest temperature, and the result was as follows: the temperature
(Centigrade) was taken over the scar and at four other points, two
inches in front of and behind the scar, and two inches distant laterally.

36.«°

External

35.6°

35.80 jjj£. 36 2°

35°

oration. — The following was the method of preparation for this and
all the other operations here* related : The room was uncarpeted, and con-
tained only Decenary furniture. The walls and ceiling were carefully
wiped the day before, and all the wood-work and furniture, as well as the
floor, were thoroughly scrubbed with carbolic solution. New, clean sponges
were used that had been kept in carbolic solution, but were used with
sublimate solution 1 : 1000 at the operation. In the first operation the
instruments were all boiled for two hours, but in the subsequent opera-
tion- this was omitted, but they were placed in a carbolic solution 1 : 20
tor a half hour, then were transferred to boiled water that had cooled
sufficiently to permit their being handled. In the first operation also,
the spray of carbolic acid was used in the room all the morning of the
operation, but not during the operation or at any of the redressings.
At the later operations the spray was entirely omitted. The day before
the operation the patient's head was shaved, then scrubbed with soap
and water, then with ether and covered with a wet sublimate dressing
of 1 : 1000, which was retained in its place by bandages until the opera-
tion began, when the ether and sublimate washings were repeated. The
hands and nails were, of course, most carefully cleaned and disinfected
by soap and water, alcohol and sublimate solution.

•ation at 1 v. >i., December 15, 1887 Present, Drs. Grove, Mears,
Roberts and the resident hospital staff, Drs. S. Weir Mitchell. Mills. White,
Oliver and Taylor, and M- - nte and Goodwin, medical stud'

Ether was used. An incuton mat uv-i made through the scar down to
the bone. By a gouge a little nick was then made in the bone so as

336 KEEN, CEREBRAL SURGERY.

to fix the site of the scar. No scar was found on the bone when un-
covered. This nick was extremely useful, as alluded to later. A large
semi-elliptical flap was then cut three and a half inches across in both
directions, the convexity posterior for drainage. The hemorrhage from
the flap was very abundant and required twelve to fifteen hemostatic
forceps, though eventually only four or five vessels required ligation.
The bone, also, when bored bled freely. This ceased without treatment.
A one and a half inch trephine was then applied so as to include the
site of the scar, the lower edge of the trephine just including the tem-
poral ridge. In attempting to remove the button the dura was found
to be adherent, especially to its lower half. Part of the bone was
markedly thinned by the pressure of the tumor. When the button was
removed the dura was found to be covered with a velvety outgrowth
one-sixteenth of an inch in thickness. There was normal sof'tii'
the anterior portion, but most of the trephine hole disclosed a hard mass
extending beyond its limits in all other directions. A second button was
then removed directly posterior to the first. The dura under the latter
was markedly protuberant but did not bulge, and the bone more eroded
than was the first. A hypodermatic needle showed a deep mass which
required considerable force to penetrate. The entire tumor was evidently
not yet uncovered. Rongeur forceps were then used to enlarge the bony
opening upward and downward until it measured two and a half inches
transversely by three inches antero-posteriorly. The upper margin
reached to within three-quarters of an inch of the middle line, when the
border of the tumor was fully exposed. The bone at this part was
greatly thickened. The lower border of the tumor dipped behind the
squamous portion of the temporal bone, which was not thickened, but
the tumor reached to half an inch below the edge of the bony opening,
as was discovered later. On incising the dura one-quarter inch from
the edge of the bone it was found to be adherent to the subjacent mass
slightly at the margins, but increasingly so toward the site of the scar
as a centre. I therefore severed its connection all round, and was able

Fio. 2.

Appearance of the tumor with tan ntta. h.'.t. Natural size. (Drawn l.y Dr. John M. Taylor.)

now to enucleate the growth by the linger with but very little force,

and lift it out from tin- underlying brain tissue and from the fossa be-
hind the iquaraoui portion of tne temporal bone.

KEEN, CEREBRAL SURGERY,

337

• //(< timer. — Weight three ounces forty-nine grains.
Displacement two and a half ounces of water. Size two and seven-
eigntha by two an<l a half inches and one and three-quarters inches in
thickness: seven and a quarter and six inches in circumference in the
two axes. Its long axil lay nearly at right angles with the median line.
App< -Non-adherent to brain tissue; intimately united with

the dura : dura and pia eapedally thickened under the scar, but gradu-
ally grew less and less adherent as the distance from the scar increased.
In the region of the sear the dura was covered with a velvety fibrous
nth. The tumor was very firm to the touch and very dense in
texture; nodular on its surface. On cross section and at right angles
with the long axis very firm ; color pinkish-white ; showing divisions
into pyramidal compartments, converging toward a centre near the
outer surface. < 'orresponding to the scar was a moderate depression on
the surface of the tumor. The two disks of bone which were removed
were very much and irregularly thinned, corresponding to the irregu-
larities on the surface of the tumor.

Fio.

Diagram of the skull showing the site of the tumor.
8, Fissure of Sylvius R, Fissure of Rolando. IP, Intraparietal sulcus. V, Vertical or precentiml
sulcus. T, Temporal ridge. I, II, III, the first, second, and third frontal convolution*. The oval
•lotted litt* represents the tumor, the cross (X) the site of the scar.

The situation of the tumor was afterward exactly determined thus :
The first bone disk was accurately fitted to its corresponding irregulari-
ties on the tumor. The nick in this bone disk was at the site of the scar,
and the position of this on the skull was one-half of an inch above and
in front of the superior stephanion. By measuring from the nick to
the edges of the tumor, anteriorly, posteriorly and transversely, and
transferring these measurements to a skull from a point corresponding
to the scar, its exact location was fixed. On this skull the chief fissures

338 KEEN, CEREBRAL SURGERY.

of the brain were also marked. It was found (Fig. 3) that the tumor
reached backward nearly to the fissure of Rolando, forward (two and a
half inches) into the bases of the three frontal convolutions, especially the
second and third, upward into the external part of the first frontal con-
volution and downward nearly to the fissure of Sylvius. Taking one of
Dalton's sections and applying on it the measurements of the tumor,
Fig. 4 shows the region involved in depth in the normal brain.1

Fig. 4.

Diagram tu show the depth of the tumor in Case I. The shaded part represents the tumor. The section
mi " Dalton's Topog. Anat. of the Brain," Series C, Plato VI. (Drawn hy Dr. S. C Wood.)

Drs. Allen J. Smith and F. X. Dercum kindly examined the tumor
microscopically, and found it to be a fibroma "showing a tendency
toward ati arrangement in bundles of fibrous elements. To the rij,rht in
the drawing (Fig. 5) is a transverse bundle of fibres having a peculiar
tranduoenl appearance as of some secondary degeneration." They
deemed the tumor to be an old and not a recent growth.

No vessels required ligation in the dura, but several large veins of the
brain poured out abundant streams of blood during and after enuclea-
tion of the tumor. I tied three or four of these with difficulty. Several
time-, in attempts to secure them, the ligature cut through, either from
to,, tight tying, or tore the vessel completely by slightly unequal traction,
either on one end or the other. Most careful gentle traction, evenly ap-
plied to the ends of the ligature. jusl sufficient to arrest the bleeding, an-
1 best. The material used wa< BLocher catgut. The hemorrhage
wae still rather profuse. The wound was therefore douched with hot

I l\\ u II n r .1 nn own thi- in a trifle too de p.

KEEN, CEREBRAL SURGERY.

339

( 115° to 120° F.), and direct pressure by sponges was tried. The
bleeding was thus finally controlled.

Fio. 5.

Microscopical appearance of the tumor in section. (Drawn by Dr. Allen J. Smith.)

The bottom of the cavity occupied by the tumor was softened, and in
part shreddy, white brain tissue ; the margins of the cavity, where dis-
closed, showed apparently healthy brain convolutions covered by the pia
with large dilated and tortuous veins. During the time occupied by
controlling the hemorrhage, the cavity left by the tumor had been filled
up nearly one-half by the resilient brain tissue. Rubber fenestrated
drain? were introduced at two points in the posterior border of the
wound. A bundle of horse-hairs was then carried from one opening to
the other across the wound. I had intended, if possible, to replace the
buttons of bone as well as the small fragments that had been kept in a
bowl of carbolized solution (1 : 40) which was placed in a basin of
water maintained at a temperature of 100° to 105°, but the sacrifice of
the dura prevented this step. The scalp wound was next united, and a
small sponge, with a larger one over it, was placed upon the flap so as to
depress it and to some extent obliterate the cavity with a view to pre-
vent hemorrhage, and facilitate union with the flap. A thick dressing
of sublimate gauze, rubber dam and muslin bandage completed the
dressing.

The operation lasted nearly two hours. Most of this time was re-
quired for trephining and checking the hemorrhage. The patient bore
the shock and large loss of blood very well. Xo motor symptoms
occurred daring the operation. When placed in bed he rolled persist-
ently to the left side and drew both legs up. He vomited four times
between 3 and 9 p.m.; probably this was the cause of some slight oozing
next noted.

Dec. 15, 9 p.m. Perfectly conscious; called me by name. Aphasia
somewhat marked. If pricked by a pin in fastening the bandage, he
always said, " the grasshopper picketh." The pupils were equal and

340 KEEN, CEREBRAL SURGERY.

rather dilated ; no paralysis ; slight pain. Morphia was given as needed,
and small do.ses of lime water and milk given every two hours. As the
droning was saturated with blood, it, as well as his night shirt, was
changed. He sat up in bed voluntarily aud thrust both arms through
the sleeves of the shirt.

From this date for a week the temperature varied from only a little
above to a little below 100° F. The catheter was required for only one
day. He suffered little or no pain and was hungry. The dressing had
to be changed twice a day for two days, as it was saturated with blood
or bloody serum. But his aphasia increased markedly and the flap
became much rounded upward. By the third day the large clot, which
had formed iu the wound cavity, disintegrated ; part escaped by the
drainage tubes, and part, with some shreddy cerebral tissue, by pressure
and gentle washing out by sublimate solution followed by cooled, boiled
water. The amount of the clot I estimated at four ounces, thus exceeding
by one and a half ounces the volume of the tumor. The aphasia dimin-
ished almost immediately. One tube was removed on the fourth day.
Four of the eleven sutures were removed on the fifth day, and three
more by the seventh, nearly all of the wound having united by first
intention. His mental condition was continuously clear. No anaesthesia
when tested by the sesthesiometer.

The next week was full of peril. His temperature rapidly rose, till,
on the tenth day, it reached 104.2° F., but by the fourteenth day was
down to the normal. All but two sutures were out by the eighth day,
and the second drainage tube shortened to one inch, and all the horse-
hairs out but two. But on the eighth day his aphasia, which had nearly
disappeared, began to increase again; his right lower face was less
mobile, and the catheter was again required. Marked and increasing
bulging of the flap was seen, and on the ninth day, without sensory
disturbance, his right arm was noticeably paretic, the left showing no
change. The dressings were saturated with a watery discharge, but no
pus. The second drainage tube was out. By the tenth day the face
and arm were distinctly paralyzed ; speech very thick, and later unintel-
ligible; aphasia marked; deafness increased. Mind clear throughout
The following day the right leg was paralysed. Along with the high
fever and other symptoms, apparently due to pressure, he had a sharp
iliarrlma, with very fetid stools. His bowels had not been moved till a
week after the operation in spite of enemata and mild laxatives.

Fearing an accumulation of pus as the cause of all the danger, I
reopened the wound with my finger to over half its extent. This dig-
closed a mass of tissue somewhat discolored, swollen, soft and friable.
not very vascular, resembling white brain tissue. The microscope
Showed no |ni-. but only fatty and granular cells and (Ubr%». The sub-
limate dressings were continued. The diarrhoea was met with opium and
acetate of lead and bismuth. His liquid diet had not been changed,
hut all food was now sterilized. Quinine < 10 grains) and moderate doses
of brandy were also given.

By the end of the second week the diarrhoea and fever were gone,
aphasia and deafness diminishing, and the flap W8J adherent to the brain

10, which had now formed a slight hernia cerebri through the 01
eeiitir opening. He was so much oetter that some oysters were given
and neatly enjoyed. During the third week his temperature varied
but little from the normal. The right leg improved very much, the

KEEN. CEREBRAL SURGERY. 841

arm snd oaining paralyzed till the end of the week, when the

in to regain its mobility. The aphakia Irmnnod also. The
hernia cerebri had increased eonaderably. Boob granulations sprang
up all over its surface, and a small amount of distinct pus was discharged
daily. The dressings had to be changed daily, chiefly on account of a
limpid fluid which escaped in abundance from two pin-hole openings
in the hernia cerebri. This was not glairy, and in appearance resembled
cerehro-spinal fluid. This abundant, limpid discharge only ceased at
end of the fifth week.

In the fourth week another sharp rise of temperature took place for
tw<> days, up to 102.6° F., and with it a marked purulent discharge from
the right ear and constipation. The attack yielded to liquid diet, laxa-
tive? and antipyrin, with washing out the ear. His aphasia was now
nearly gone, and the facial palsy considerably lessened. On the twenty-
Dth day he moved his right arm once at the shoulder only, but
could not repeat the movement ; on the twenty-eighth he could bend his
elbow, the finger movements being barely perceptible. The right nails
shown by staining with nitric acid) had grown decidedly less than
the left. He was hungry and was sitting up.

In the fifth week the temperature twice rose quickly for two days, and
one day to 102.4° and 1023 F. respectively, apparently due to constipa-
tion, for an enema caused a quick decline. With each of these attacks
of fever his aphasia and the palsy of the right arm immediately increased,
and as quickly bettered with the fall. By the end of this week the
eat of motion at the shoulder and elbow was complete, though much
feebler than normal, but flexion of the fingers was only perceptible.
By the fortieth day the finger flexion had increased to the normal in
extent, but only to about half strength ; he could extend the fingers
slightly, but could not repeat the extension, though he could the flexion.
At the wrist he had flexion, but not extension. On the forty-second
day he could extend the wrist, and from this time on he steadily gained
in extent and power of motion in all directions.

The temperature now fluctuated but little from the normal till he left
for home. The hernia cerebri had been strictly let alone, only the sub-
limate dressings being changed, at first daily, on account chiefly of the
watery discharge until the thirty-seventh day, after which time they
were only changed every two to three days, the watery discharge haying
then ceased. The hernia was covered with granulations, but, as they
slmwed very little tendency to cicatrize, on the thirty-fourth to the fiftieth
day thirty-tour skin-grafts from his arm were used to hasten the process.
Of these, all but four adhered; several that became detached during the
dressing were immediately reapplied and lived. The potassio-tartrate
of iron was used for some days with advantage under the sublimate
dressing, and removed a membranous film which existed between the
grafts. On the seventy-first day cicatrization was complete. The hernia
had been for some days nearly on a level with the skull. The next
dr-ssingwas on the seventy-fifth day, when the site of the hernia, instead
of being an elevation, had suddenly changed to a deep hollow.

ity-fourth day . Went home well. Nails on the right
hand still halt stained with nitric acid ; on the left a barely perceptible
band. Surface temperature, left side, one-half inch anterior to the old scar,
95.1 F. : right, corresponding point. !»b'.4° F. Dynamometer, R. 23°,
L 30°. While using the dynamometer the depressed scar rose to the

342 KEEN', CEREBRAL SURGERY.

level of the skull ; any marked expiratory effort or even leaning forward
to the horizontal position has the same effect. Front tap marked on both
sides. Knee-jerk: right much diminished, left exaggerated. Elbow-jerk :
right side exaggerated, left diminished. The hernial scar is a crescent,
mottled by the skin grafts, two and three-eighths inches long, seven-
eighths of an inch wide and five-eighths of an inch deep. Mind clearer
than before the operation.

April 19. Dr. Davis writes that he had an epileptic attack yesterday
at breakfast. The attack was slight and came on slowly, the head and
body turning to the right. Otherwise well and gaining flesh.

I owe much to the intelligent care and faithfulness of Dr. J. C.
Heisler, the surgical interne, and he made most of the observations of
the temperature, reflexes, etc. I must also express my obligations to
Drs. Davis, Oliver, S. Weir Mitchell, M. J. Lewis, William J. Taylor
and J. M. Taylor for help in many ways in all three cases reported.

I append Dr. Oliver's later observations of his eye symptoms. These,
with observations from the other two cases, he will publish in extenso
later.

" Immediately following the operation, and at stated intervals of two
weeks' duration each, the eye-grounds were carefully reexamined, the
state of the muscles retested and the conjunctival sensibility retried, but
in no instance could any changes be found. Of intense interest, how-
ever, were other changes. Two months after the operation the fields of
vision, although retaining the same positions and embracing the same
areas, were found to have gained partial color definition. The left field1
showed distinct and well-mapped areas for yellow and blue, with a small
spot in which red was designated as ' lead,' whilst the right field gave a
trace of color differentiation in a small central area. On the same date,
the poiut of best sight with the left eye — even according to the patient's
account — had gradually increased to qualitative vision ; letters of num-
ber thirty dioptry type being properly named when swept across the
situation of the best projection in the eccentric field. With the right
eye nothing definite could be determined, the patient constantly twisting
In- head in various positions and suddenly exclaiming, from time to
time, ' I see a black mark,' or incorrectly calling an exposed letter.

"Careful study of these symptoms, in association with the history,
shows that there were most probably two distinct factors in their pro-
duction: First. An irritative cortical and subcortical growth occupying
a position in the left motor zone, encroaching upon, and, in fact, altering
the centres for the right upper and lower extremities, the centres for
lateral movements of the head and eyes to the right with elevation of
the eyelids ami dilatation of the pupils and the centre for elevation of
the right angle of the mouth ; beside indirectly pressing upon and per-
haps changing the left visual and auditory centres or their efferent
strands' Second. A resultant destructive basilar lesion including por-
tions of both leoond nerves posterior to the chiasm, parts of both third
Mrves, fi laments of the sensory and motor branches8 of both fifth BSl

i In writing to mi. before the operation the patient, referring; to his eyesight, by a curious error

his the "left 1.1.1.1."— W. W. lv.
» It If probable that the right visual an.l anlit >ry o.ntres or outgoing strands were in someway
impinged upon, possibly by the brain MM itself.

v..lv,.m.Mit of this nenre is, of course, questionable, if the lesion or Its indirect resnlta
•re supposed to hare gained access to the nuclei of the motor ocull.

KKKX. CEHEBHAL SURGERY.

343

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344 KEEN, CEREBRAL SURGERY.

and both eighth nerves,1 apparently more profound upon the left side
during the acute attack upon account of the passing results of the co-
existent irritant lesion, but in reality greater upon the right.2

"At first, although by the most careful scrutiny of the patient's person
there could not be found any characteristic sequelae, it was thought that
an old gummatous thickening, with a subsequent basilar meningitis from
acquired syphilis, would account for these two distinctive character.-; of
lesion, and, in consequence, he was placed for a reasonable length of time
upon large doses of the alteratives. This partially diagnostic treatment
not producing any effect whatsoever in five months' time, the growth
was decided to be of a different nature, probably traumatic in origin ;
and, after consultation, an operation seemed justifiable."

For two weeks Dr. Heisler made careful comparative observations on
the temperature of the two sides of the body, the points selected being
the axillae, the brow, palms and legs ; the results appear in the accom-
panying tables. The right side generally showed the lower temperatures,
except in the palms, where the right was, on the whole, the higher. The
temperature of the legs was about 1° lower than the rest of the body.

Remarks. — I confess that I was very reluctantly brought to the con-
clusion not to operate when this patient first came to me. But the early
history, as detailed in this paper, is largely corrected and pieced out by
facts learned later, some of them even after the operation. When first
seen, the site of the injury was extremely doubtful. Shaving the head dis-
closed scars, and the clinical history reported no scar of sufficient moment
to be remembered. Even which side of the head had been injured was
doubtful, and the most contradictory statements were made as to the
initial symptoms of his fits. On the whole, the evidence was mostly in
favor of the left side, but there were no local symptoms at or near the
scar ; the old suppuration of the right ear raised great doubts as to how
far that might be the cause of a right-sided cerebral mischief, while, still
further to complicate the problem, Dr. Oliver was of opinion that the
ocular symptoms pointed to an old syphilitic lesion in spite of the denial
of the patient. It seemed probable that there was a dual lesion, one
the result of the ear disease, the other a still existing meningeal trouble,
causing irritative discharges, which might be lighted up anew by any
operation. But as no improvement came during several months of
treatment, I decided, positively, to operate.

The diagnosis made by Dr. Davis was the one finally arrived at by all
of us, the probability being in favor of tumor rather than of exostosis, or
cicatricial thickening. This was based on the extent of the palsy, the

' A peripheral complication Id the acute attack of catarrhal" the right middle ear, early in life, should
tie remembered.

* TheM conclusions, which, of course, must remain sub judice until post-mortem evidence, are r»n
dered still more certain by the results of the operation, where it seems probable that a long-standing,
quiet and slowly growing neoplasm at last reached a sufficient size not only to encroach upon the adja-
cent motor tones and thus give rise, in jiait, to convulsive discharges, but to cause an actual inflam-
matory attack, during which sjaaptUUH of l«Mh irritation and destruction showed themselves; Om
former gradually lessening and the latter persisting.

KEEN, CEREBRAL SURGERY,

345

. arm ami leg beinjr all involved, with aphasia; but I did not at all
anticipate, nor do I think any of my colleagues did, that the tumor had

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Legs (near crest of tibia).

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Axilla. Palms.

Temperature of the lea side shown by continuous line*.
Temperature of the right side shown by dotted lines.

attained such enormous size. It is not surprising that so large a mass
caused epilepsy, aphasia, complete hemiplegia, intense neuralgia, deaf-

340 KEEN, CEREBRAL SURGERY.

ness in the left ear and blindness ; but the wonder was that, excepting
the ear and the eye symptoms, all the others had passed away except a
slu \\ ness of speech and the epilepsy, and even this was much better.
No function was absolutely destroyed, nor was there any external
change in the bones or the sutures of the skull.

The clinical history, as well as the microscopical examination, seems
clearly to show that the tumor began at the time of the injury and was
slowly growing for twenty-four years until its removal. For twenty years
it gave no material sign, although his rather sluggish mental state is un-
doubtedly to be ascribed to it. Then it suddenly burst out in disastrous
activity. The regions that would be involved in a normal brain (Figs.
3 and 4; can hardly be deemed as at all an accurate representation of
the localities actually involved, for, 1, its size is such that remoter parts
must have suffered from the direct or remote pressure; 2, many of the
sequels are due to resultant meningitis, especially at the base; and 3, as
the brain and the tumor almost began life together and certainly "grew
up" together, the brain accommodated itself to its intruder to a great
extent, and its cortical centres and even the great basal ganglia were
doubtless displaced into regions that we can only guess at. Thai the
tumor reached very nearly to the lateral ventricle, and that later the
resilient rising brain layer between the tumor cavity and the ventricle
broke down, is probable, not only by the sectional diagram of the rela-
tions of the tumor and a normal brain (Fig. 4) but also by the abun-
dant and long-continued discharge of cerebrospinal fluid. Sometimes
this poured out almost in two distinct jets.

I was greatly astonished — it being my first experience — at the rapid
filling up of the cavity left by the removal of the tumor. Within per-
haps twenty minutes it was half filled up. In Cases II. and III. the
same phenomenon occurred but only to a moderate extent, as was natu-
ral, there being little if any increased intracranial pressure. Thi> ex-
passion of the brain is no doubt of great use in bringing its surface and
the ilaps in contact ami so facilitating their union. It is also to a
extent the cause of the hernia cerebri which pushes through anv opening
in the skull and scalp. Hence the whilom, in most cases, of removing
the drainage tube at the end of twenty-four hours, and of the earliest
possible entire healing of the wound. The treatment of the hernia
Cerebri by absolute' non-interference and not by shaving it <jfff i< that
which i- now. 1 believe, generally deemed best by surgeons, and cer-
tainly resulted vary happily in my case. The skin-grafting upon its
granulating surface succeeded even better than it generally does upon
other parts of the body.

The hernia WSJ dressed with dry sublimate gauze I 1 : 1000) for about
tta m no ill effeota resulted. The first serious rise of tempera-

tan could not be attributed to the mercurial, for the wound up to that

KEEN, CEREBRAL SL'RGERY. 347

time was a mere linear one and had nearly healed. I greatly regretted
that I re-opened the wound, thus allowing the hernia to follow and cam—
such long delay in the healing. Looking back upon the entire
history, it is evident that the fetid diarrhoea was the cause of the high
temperature and was itself, probably, the result of the prior obstinate

- -i pat i<>n. It seemed more probable and reasonable, however, at the
time to attribute the diarrhoea, the bulging of the flap, the aphasia and
the progressive hemiplegia to intracranial pressure ; and concealed sup-
puration was the most likely cause for such pressure. But when he had
several later attacks of fever with diarrhoea or constipation, the aphasia
and paralysis again fluctuated in a curious and instructive way, more
with the general condition, and especially with the fever, than with any
possible alteration in the intracranial conditions.

A careful study of the surface temperature of the head was made, as
en by the notes. The only inferences seem to be that, before the
operation, the left side had about the normal greater heat than the right ;
but it is a rather curious fact that while this was true even of the brow,
the right cornea was 0.6° F. hotter than the left. Three months after
the operation, too, it is noticeable that the right side of the head was
0.7° F. hotter than the left — a rather curious fact, though Broca gives
the right parietal temperature as 1.35° F. higher than the left. The
other comparative temperatures are placed at the end of the history.

Dr. Heisler made daily examinations of the urine for some weeks,
but. except that it became scanty and high colored during the febrile
attacks, there were no other changes.

He also made very numerous examinations of the patellar, abdominal
and cremasteric reflexes. Two days after the operation they were all
normal but the knee-jerk was not reinforcible. The later observations
vary extremely and seem to follow no law. Sometimes the right side

- greater than the left, sometimes it was reversed, and in different re-
flexes it was not always the same side that preponderated at the same
time. Sometimes one reflex would be normal or increased, while another
would be diminished ; sometimes all would vary similarly. There was
apparently no relation between the variations of the reflexes and the
fever or other physical factor. Before the operation the left knee-jerk
was normal ; right subnormal. Six days after it, the left was exagger-
ated, the right much diminished ; while in the elbow-jerk the reverse
was then found. We had no instrument by which to measure the knee-
jerk, and I do not rely, therefore, implicitly on these observations,
except that they certainly show a curious variability, seemingly without
any law. In its histological structure the tumor is very rare. Only 3
fibromata appear in the 580 intracranial tumors tabulated by Bernhardt
and Hale White. It is equally gratifying in the entirely favorable
progi .

348 KEEN, CEREBRAL SURGERY.

Case II. Simple depressed fracture of skull, followed in four month*
by epilepsy; thirteen month* later trephining and removal of damnr/rd
bruin tissue; recovery in seven days; cure of epilepsy to date. — D. B. L.,
of Kansas City, was sent to me April 8, 1888, by Dr. W. C. Roller, of
Hollidaysburg. Aged twenty-five ; best weight one hundred and fifty-
four pounds, present weight one hundred and fifty-two and a half pounds ;
five feet eleven inches in height; American; civil engineer. Had the
ordinary diseases of childhood, except scarlet fever, from all of which
he recovered perfectly.

At seventeen, in the summer, while in the engineer corps of a railroad,
walking fast to catch a train, he felt dizzy and his head commenced to
pain him. He was in bed for a week and in the house for ten day-.
The headache was not well located. So far as he remembers his head-
aches were of equal severity both before and after this, occurring from
one or two in a month to one in two months. He always could predict
them by a twitching of the eyes and by waves as of heated air passing
before either the right or left eye. From seventeen to twenty-two he
was in school, and since 1885 has been a civil engineer, in the office in
winter and in the field in summer.

In November, 1886, he fell one night a distance of nine feet. His
face was scratched and he had a serious blow on the right side of the
head, without, however, any lesion of the scalp. He was unconscious
for a considerable time. When he came to, about daylight, he found
himself in bed and entirely conscious. After dressing he came down
stairs and took a car to his sister's, where he was confined to bed for
three or four days. A week after the accident when he first tried t<>
dress himself again, he noticed that the three left ulnar fingers had lost
their feeling. He could move them but they felt strangely unnatural;
especially toward the tips. He had some difficulty in buttoning bis
collar and in other such finger actions. There was no other paralysis,
and no catheter was necessary.

The headaches after the accident were about as usual, possibly less
severe. He returned to business in about a month.

M :,■!, 8f 1887. At 9 a.m., while waiting for a street car, he suddenly Kit
ili/./y ; starting to walk he swayed to and fro; called a policeman, but
before one reached him he fell down unconscious. He recovered in s
few minutes, and found that his left hand and forearm were paralysed.
After the policeman had rubbed his hand and arm tor a few mini;
he completely recovered the use of them. He is quite sure that his
shoulder and elbow were not affected. Though he felt able to go to
work be did not resume his place at the office until the following day.

In dune, 1887, he bad a duty spell, which was relieved by the appli-
cation of hot water to the head.

In September, 1887, being unusually well after his summer holiday,
he suddenly felt quite dizzy. Fearing an attack he ran the length of a
long hall back to his office, and lay down on the floor and became un-
conscious. He woke an muddled after ten or fifteen minutes. A
brother clerk states that " hi- eves were first open and fixed, then his
head was tossed from side to side, with considerable general convulsive
movement, and later considerable rigidity of the body. He turned his
body like ■ corkscrew, and especially kept his head down pounding on
the Boot with his forehead His face and hand.- were dark blue, cold

and damp. Than was frothing at the mouth, and later s.. me loss of

KEEN*. CEREBRAL SURGERY. 349

memory for some little time." The hands were not affected in any way.
hut both eyes were as " red as flannel" for three or four days. In an
hour or Iwo he returned to his work in the office. These attacks were
always ushered in by palpitation of the heart and a rushing sound in
the ears. After these attacks, of his own accord, he took bromide
(about a drachm a day) until the 25th of February, when he stopped on
account of the acne.

h 1, 1888. While walking in the street he felt a dizzy attack
coming on. He walked perhaps seventy-five feet and became uncon-
scious. After he recovered he walked home and remained in the house
for some days, but not in bed. He was nervous, but otherwise well.
Il> hand was not affected. He was generally constipated before these
attack-.

. He knew that an attack was coming on by the dizzy feeling and
the sensation of numbness which he could not locate ; by gasping for
breath and by wanting more light in the room. He became unconscious,
but did not fall from his chair. The hand was not affected after it.
His sister, who was present, states "that his convulsion began with slight
movement from side to side, increasing in violence ; the face was swollen ;
the eyes open wide and very red ; twitching of the head and face ; left
forearm and leg stiffened ; no convulsive movement, except a little
twitching of the left fingers; breathing was snoring and there was
frothing at the mouth. He was unconscious for ten minutes. This
attack was followed by temporary loss of memory, confused talking,
etc." Later on, in the same day, another attack was aborted by the use
of cold water on his head, which was very hot.

April 8. Present condition : Urine normal ; no albumen, no sugar.

Head. — When his head was shaved two small scars were found, one
unaccounted for and one from an old hurt. In addition to this, five-
eighths of an inch behind the apex of the right parietal protuberance
and on a level with it was a shallow groove running upward and forward
at an angle of 50 degrees with the median line, the angle opening poste-
riorly. The groove was about two and a half inches long and one-half
of an inch in width. The ends were not definitely marked ; the centre
was three inches to the right of the middle line. The anterior end of
the groove died out just in front of the bi-auricular line and just anterior
to the fissure of Rolando.

The anterior portion of the groove slightly overlaps the pre-Rolandic
convolution, crosses all of the post-Rolandic convolution, and the poste-
rior portion of it is over the supra-marginal. The scalp showed no lesion.

Dr. J. M. Taylor determined the following facts : " Knee-jerk and
reinforcement normal. Dynamometer: right, 160° ; left, 150°. Sensation
in hands by the sesthesiometer, normal and equal. Station, sway one-
half of an inch posteriorly, and then three-quarters of an inch forward ;
to right one-half of an inch ; then left one inch. Electric reaction by a
faradic current, normal."

Dr. Charles A. Oliver examined the eyes and made the following
observations : " Direct vision for form, normal in each eye separately.
Range and power of accommodation in each eye, proper for refractive
error and age of patient. Fields of vision for form and color, normal
in area and sequence. No evidence of subnormal color-perception.
Pupils equal in size and shape upon separate and conjoined examination.
Irides freely mobile to light-stimulus, accommodation and convergence.

350

KEEN, CEREBRAL SURGERY.

Iris of right eye not so responsive as its fellow to light-stimulus in
monocular action ; there being a difference of one and a half millimetres
in the size of the two pupils after the utmost action in myosis. No
changes in the eye-grounds except those found in used hypermetropic
eyes at patient's time of life. No perceptible anisometropia. Slight and
almost imperceptible insufficiency of the interni."

The temperatures were also taken by Dr. Taylor over the scar and
two inches in front, behind and externally, and at the three correspond-
ing points on the left side, with a centigrade surface thermometer as
follows :

:«°

:h.9°

34.9°

(2 inches.)

34.9°

(2 inches.)

34.5°

35.4°

l)i<i<jnom. — Traumatic epilepsy from depressed fracture of the skull,
with probably a fragment of bone broken from the inner table ; possibly
a cyst of the brain ; certainly, secondary traumatic changes. Centre for
the left hand and the supramarginal gyrus involved.

I recommended that an operation should be done, and he gladly con-
sented to it.

Operation, April 12, 1888— Present : Drs. W. J. Taylor, Mills.
BfaUer, Lloyd, J. W. White and Morris J. Lewis, of Phila./C. M. Ellis.
of Elkton, Md., and Mr. Lie Conte, medical student.

I had intended giving the patient a quarter of a grain of morphia to
contract the cerebral vessels, as Horsley has advised, but be informed
me of the bad effects of that drug upon him, so I substituted one drachm
of the fluid extract of ergot half an hour before the operation.

The previoui day his head had been shaved and treated as described
in Case I. Similar precautions wore taken as to hands, instruments,
sponges, etc. No spray was used.

Kther was administered and a horseshoe-shaped incision, three by
three and one-quarter inches, was made, extending beyond the limits of
the depression, with the convexity backward. Hemorrhage from this
wound was admirably controlled by the flat hand furnished with the
ordinary Esmaroh bandage. Eventually only three arteries in the seal])

KKEN. CEREBRAL SURGERY. 351

required ligation. The loss of blood from the scalp wound was not over
half an ounce. As soon as the flap was raised a sharp furrow, about

sixteenths of an inch in depth, was seen in the skull, showing evi-
dently the old Line of fracture through the entire thickness of the bone.
This could not well be appreciated through the thick scalp. An inch
and a half trephine was now applied directly at the middle of the

sion.

Fig. 8.

Diagram of skull.
S, Fissure of Sylvius. R. Fissure of Rolando. IP, Intraparietal sulcus. T, Vertical or precentral
•ulcus. T, Temporal ridge. I, II, III, The first, second, and third frontal convolutions. The
dotted line represents the opening in the skull ; the inUrrupttd oval line, the furrow in the skull
ikaded portion represent* the part excised; the circle representing the cyst. (Drawn by Dr. John M
Taylor.)

Care was taken, on account of the inequality of the surface of the
bone, not to cut through the elevated portions in advance of the depres-

of the furrow. As soon as the disk of bone was removed it was
placed in a teacup, in a bichloride solution, 1 : 2000, which Dr. Lloyd

careful to keep at 105° F., by hot water in an outer basin. All the
later fragments removed were put in this cup for future use, should it
not be needful to remove the dura mater. The inner surface of the
button showed a ridge corresponding to the old fracture. There was no
bulging of the cranial contents, and they pulsated regularly. The dura
mater in a line corresponding to the fracture was dark and thickened,
and looked as though a large vein or sinus was under it.

A small opening was made in the dura, and, by means of a probe, it

found to be distinctly adherent to the brain, underneath and beyond
the limits of the opening. Accordingly, by a rongeur forceps, the open-
ing in the bone was enlarged three-quarters of an inch backward, to a
point somewhat beyond the line of the old depression and half an inch
anteriorly, until, finally, it measured three and one-quarter inches an-

352 KEEN, CEREBRAL SURGERY.

tero-posteriorly and one and one-half inches transversely, and exposed
all tin- adherent portion of the dura. An incision was now made in the
dura mater, with the convexity backward, one-eighth of an inch from
the margin of the opening in the skull, and the whole dura mater was
detached from the brain, until the non-adherent portion was reached,
both posteriorly and anteriorly. This lifting tore the brain substance
to which the dura was intimately attached. The portion of the brain
underneath the line of the scar was brownish-yellow for nearly a finger's
breadth, of normal consistence anteriorly, but at the posterior extremity
was distinctly hard. In the centre of this indurated portion a small
cyst was discovered about one-quarter of an inch in diameter. Its con-
tents were apparently serum. Some little hemorrhage from the vessels
of the brain occurred at this time, when I tried the effect of cocaine
applied on a pledget of borated cotton. This solution was made with
recently distilled water, the bottle and its cork having been disinfected
by bichloride solution and then washed with distilled water. The effect
of cocaine was certainly very happy. It contracted a number of blood-
vessels that otherwise would have required ligation. Three vessels were
ligated with Kocher catgut and no further serious trouble was experienced
from hemorrhage. The walls of the vessels were not friable and bore
the ligation well. Neither pressure nor hot water was required and the
vessels that were not ligated were controlled by cocaine.

The brain substance was so matted together in the line of the scar
that it was impossible to distinguish one convolution from another. All
the brain substance which was altered in color, including the thickened
walls of the cyst, was excised to about one-third of an inch in depth
anteriorly and nearly two-thirds posteriorly. The entire amount of
brain substance excised would be, perhaps, one teaspoonful. The
incision was made vertically to the surface and but little hemorrhage
accompanied the removal of the brain substance.

At the time of the excision of the brain tissue Dr. Morris J. Lewis
observed the following phenomena, which were all corroborated. How
many were due to the act of cutting I leave to the reader to decide :
" Patient yawned twice contracting the face evenly i previous to yawn the
creases in face were slightly more marked on right side). Opened eyes
ami rolled them slowly ; slight external strabismus of both eyes; pupils
moderately dilated and equal. No conjugate deviation.

'* During the whole of the cutting there were no movements observed
in the left arm or hand, but once or twice conscious movements r
made with the right arm and both legs, the righl leLr moving the most
igly.

A ionic contraction, lasting but a short time, was noticed in l>jt leg
(a similar contraction in thumb, in palm and flexion of wrist occurred
in left arm daring etherization and before operation).

"After the catting, and while the patient was still under ether, the fol-
lowing condition of the reflexes in the le<_rs was noticed:

- Ryhi knee-jerk exaggerated; left knee-jerk about normal. Right

ankle-jerk marked; l-jt ankle-jerk very slight. A tendency to clonus
■ ..lie mi- two throbs, was observed in right foot, none in left."

1 had taken my camera and two Cramer plates. No. 28, and at this

the prooeedingfl Dr. Morris J. Lewis, at my request, took two

photographs of the wound, the exposure in each one being ten seconds.
This was the Only interruption in the operative proceedings. The day

KEEN. CEREBRAL SURGERY. 353

cloudy and the light poor and the patient moved slightly, so that
the tir>t photograph was worthiest, but the Kcond is fairly good.

I then removed the ahead J nearly detached dura mater corresponding
to the entire length of the scar. On its inner surface a small spicule of
bone, size one-quarter inch, was discovered. It was attached to the under
surface by one end. It was imbedded in the brain substance, but whether
it had any relation to the cyst could not now be ascertained, though
it most probably had. The button of bone which had been remoi
was now completely perforated at its middle by the centre pin of the
trephine and another hole was made toward its margin. It was then
placed on the under surface of the flap and secured in place by a chromic
acid catgut ligature, the two ends being passed through the openings in
the bone and then through the scalp and tied on the outside to prevent
its falling upon the brain substance, and to secure its adhesion to the
scalp.

The scalj) wound was now united by chromic catgut ligatures placed
quite closely together. A rubber drainage tube was brought out of the
posterior part of the wound and about a dozen strands of horsehair were
passed entirely through the wound. An ample bichloride dressing was
m>w applied to the entire skull.
. Twice during the operation his respiration and circulation had been

Sor and a number of injections of brandy were made in the forearm,
e was placed in bed surrounded by hot bottles. The operation lasted
one and a half hours and his temperature, at the close of it, was 97° and
the pulse 102.

April IS, ♦> p. m. As the dressing was saturated with blood the wound
was redressed. The left hand was distinctly paralyzed, as follows: The
fingers and wrist cannot be flexed. Any attempt at flexion results in
extension of both fingers and wrist and separation of the fingers. 9 p. m.
Temperature 98.4° F.. pulse 98. Had a very comfortable sleep ; suffer-
ing no pain : vomited only once.

J-Jth, ,s.lo a. ML first day after operation). Temperature 99° F. He
passed a quiet night on the whole. Being hungry, I ordered him to have
coffee and rolls for breakfast and milk every two hours. At 11.55 last
night the nurse tested his hand and found no power of flexion. At mid-
night he repeated the experiment voluntarily and found flexion in both
wrist and fingers. I examined him, however, and found this flexion is
effected by the superficial and deep flexors only, which flex the last two
phalanges, but the knuckle-joints, which are flexed by the interossei,
cannot be flexed. He makes a fist by flexing the last two phalanges
and rolling the flexed fingers into the palm (as in ulnar palsy i. He
can. however, touch his fingers with his thumb. When he desires
clench the fist tightly he flexes the fingers as described, and then the
flexors are put further on the stretch by extending the wrist. As the
dressing was saturated with bloody serum and a little blood, it was
changed.

'I p m. Temperature 99.8° F., pulse 88. The rise in his tempera-
ture was probably accounted for by some worriment due to his mother's

:ice, who was a stranger in the city. He has only two complaint-
make, one that his right arm is very sore from the brandy injected
during the operation, and the other that he is hungry. I directed a
more liberal allowance of milk to be given to him with some bread and
butter or toast. The dressing was a little moist, just saturated on the

854

KEEN, CEREBRAL SURGERY.

outside with bloody serum only, and was changed. The wound could
not look better. The drainage tube was removed leaving the horsehair
in ritu. There was no material bulging of the flap.

14th 8 a. m. (second day). Temperature 98.4° F., pulse 86. 8 P. m.
Temperature 98.4° F., perfectly comfortable; has had do pain; feels
only a little sore ; the right arm more comfortable ; knee-jerk about
normal, both yesterday and to-day, on the left side ; slightly exaggerated
on the right ; no ankle clonus. By the sesthesiometer on the right fore
and little fingers two points were appreciated as one at one-sixteenth
of an inch ; on the similar fingers on the left side at six-sixteenths of
an inch.

15th (third day). Had a comfortable night ; temperature normal. As
he was hungry I allowed him to take two chops this morning. The only
complaint was that it was not enough. During a dream in the night he
disarranged the dressing (though the wound was not uncovered), so that
I redressed the wound. I removed the horsehairs one by one. There
was no discharge and the wound was completely healed, excepting a
very small area at the drainage opening. The temperature at noon, by
a surface thermometer for five minutes was, in the left hand, 35.4° (C.) ;
right hand, 35.5°; left forehead, 36.7°; right forehead, 36°; left leg,
35° ; right leg, 34.9°. (Dr. Win. J. Taylor.)

I'Hh (seventh day). The wound was dressed and all the sutures
removed. As the suture holding the disk of bone in place was causing
no irritation, it was left. The wound was perfectly healed, not reddened,
no soreness. The flap is concave to just about the same extent that it
was before the operation.

On the 17th (five days after the operation) he was up and dressed.
To-day he has taken a walk of one-third of a mile. The only difficulty
I have is in restraining him from reading, writing and, in general, too
great physical and mental exercise. He is on an ordinary diet. In his
left hand he has regained sufficient power to make his grip painful to
me. When he wishes to grasp with any force, however, he still increases
t he power of the flexors by extension of the wrist, thus putting the flexors
on the stretch.

Anterior.
:*4-9° 35°

I 2 in lii-s.)

KEEN. CEREBRAL SURGERY. 355

eleventh day . The .-uture holding the disk of bone in placv was
removed. No irritation at it? two openings of exit through the scalp.

. Photograph taken. His mother being ill, he goes home to-
morrow. Dr. W. J. Taylor made the following observations on his
temperature ( lentigrade).

Dr. J. M. Taylor made the following report:

"Dynamometer: right UK)0, left lJi» .

• notion. Left index finger closes indifferently well.
S asation. Slight impairment in middle forearm and third and fourth
fingers, but position of sesthesiometer clearly indicated.

"Knee-jerk: right increased, left normal ; reinforcements to normal.

'Station, normal, antero-sinistral ; antero-posteriorly. forward three-
quarters of an inch and not backward ; laterally, right half an inch,
left one and a half inches.

'.Muscles respond to the mildest faradic currents equally well on
both sides. An accident made it impossible to test them for reactions of
^■ration."

The patient called at my office to-day. The site of the
operation shows a furrow. The replaced button of bone is perceptible
and firmly adherent to the scalp. It is not adherent on the sides of the
opening. This is well shown when he bends forward, as the button can
be moved by pressure. The scalp is in good condition and protects the
opening well. He has no headaches or mental symptoms, except that now
and then he fears an epileptic attack, and this worries him. He eats
and sleeps well. He makes a fist firmly, with primary flexion of the
knuckles ; his grip is good, and he has lost entirely the " dead-like "
feeling in the three ulnar fingers. When he raises his left hand, and
especially if he grips something with it. the left forefinger twitches
noticeably.

Dr. Oliver reports the following reexamination of the eye, twenty-
four hours after operation.

"Iris of right eye responds separately, as equally and as freely as its
fellow, the pupil becoming the same size as that of the left side upon
extreme contraction, to light stimulus.

" The isolated symptom of want of proper reaction of the right iris to
light stimulus alone (a species of monocular Argyll-Robertson pupil),
which was relieved by the operation, consisting in the excision of a por-
tion of the cortex and subcortical tissue in the right supra-marginal
convolution, is, as far as the observer is aware, a new observation, and
may be of value in further determining and better localizing the situa-
tion of interruptions in the light reflex act." In Dr. Oliver's paper
later details will be given of the ocular conditions.

Dr. George Dock kindly examined the brain tissue removed, and
reports as follows :

" The specimens consist of a piece of dura mater of irregular outline,
measuring 4 cm. in length and 2.5 cm. in width, and a part of cortex
cerebri of similar outline, down to, and including the white matter.

'• The dura is divided into two unequal parti by a curved line in the
l>ng axis. This line is marked by loose connective tissue on the outer
surface, resembling the course of a meningeal vessel. Near one end a
small, smooth spicule of bone is adherent to the membrane. On the
inner surface the line is well marked, though only as a thickening
and pigmentation of the membrane. The dura varies in thickness

356 KEEN, CEREBRAL SURGERY.

from 5 mm. to 2 ram. It is deeply pigmented, especially on its inner
surface. Microscopic examination shows fibroid thickening, especially
on the inner surface, corresponding to the line supposed to represent a
cicatrix. There is also extensive perivascular and interstitial hemor-
rhage, and hemorrhage into the arachnoid spaces.

" The piece of brain substance measures 3.3 cm. in length, 2 cm. in
width and 1.3 cm. in greatest thickness. The surface is rough and dis-
colored, and shows no normal cortical surface. The edges and inner
surface show a few punctate spots, but appear healthy. The small
cavity on the surface looks like the site of a cyst, which has been
obliterated by the hardening.

•' Microscopic examination of specimens from various parts of the sur-
face show extensive destruction of brain tissue. The brownish tags on
the surface are composed of broken-down nervous tissue with pigment
masses and compound granule cells. Deeper down are perivascular
hemorrhages and collections of lymphoid cells, fine granular pigment,
compound granule cells and increased number of neuroglia cells. The
edges and inner or white matter surface show usually no change.
Only at one end are there hemorrhages and collections of small cells in
the perivascular spaces, at the margin of gray and white matter. A
section from the wall of the cavity mentioned shows no traces of cyst
wall proper. The gray matter there shows also vascular dilatation,
compound granule cells and slight degeneration of nervous tissue.

"Diagnosis. The specimens evidently show results of a chronic
meningoencephalitis, which, in the absence of any discoverable vascular
disease, is most probably of traumatic origin. The scar-like alteration
of the dura strengthens this opinion, as does also the spicule of bone."

Remarks. — It was clear from the outset that this patient had suffered
from a simple depressed fracture of the skull, and the operation showed
that the dura had been torn and a spicule of bone driven through this
rent into the brain. The brain substance also had been lacerated, and
later a cyst had been formed. The degenerative changes in the brain
were very evident to the eye, and the hardening of the cyst walls
equally so to the finger. The conclusion is clear. This patient should
have been trephined immediately after the accident, especially as, with
due antiseptic precautions, trephining is not now a dangerous operation.
In fact, the patient was lucky to have escaped an acute meningo-
encephalitis. Whether the surgeon recognized the fracture or not, I do
not know, but the patient, a very quick, bright and intelligent fellow,
made one curious observation upon himself that I commend to the pro-
fession U it may prove a useful means of diagnosis in other cases. On
the morning alter the accident he examined the two sides of his head
by tapping on it, and he says he observed distinctly a "cracked-pot
sound '* on ill" side of the injury. Whether this would be perceptible
only suhj.vtiv.'iv bj the patient, or whether the Burgeon himself could
also perceive it, is a question I have not yet had an opportunity to settle.
It nut beard by the unassisted ear of the surgeon. I would suggest that

THORNTON, ROTATION OF OVARIAN TUMORS. 357

■ stethoscope be used while the head is tapped. "Skull percussion "
may hereafter render important aid, especially in fissured fractures.

The location of the injury was clearly mapped out as over the hand-
<< litre in the post-Rolandic convolution and over the supra-marginal
convolution. The early clinical history indicated the involvement of
the hand-centre, and the results of the operation were strikingly con-
firmatory. The very early return of the hand movements was prob-
ably due to the fact that M compensation " had already been effected
soon after his accident, and that spoiled, and not normal brain ti-
removed. The injury of the supra-marginal convolution and subsequent
removal of the degenerated tissue would seem to have some causal con-
nection with the " monocular Argyll-Robertson pupil " symptom, noted
by Dr. Oliver, and may prove of value in the future.

Normally the left side of the head shows a somewhat higher surface
temperature than the right. It is interesting to note that in this case
the injured (right) side before the operation was distinctly the hotter of
the two, and that only twelve days after the operation its temperature
fell about 1° C, a point below the temperature of the left side — i. e., its
normal relation. It would seem that not only was there no inflamma-
tory heat left as a remnant of the operation, but that the removal of the
injured tissue had cut off the source of irritation and resulting heat.

Along with this it is to be noted that there has been no return at
present 'August 12th) of any fit. Though this period of immunity
(four months) is too short to warrant any definite statement of results,
yet, if we observe that before the operation the fits, though infrequent,
were growing more frequent as time went on : that the tits have not
rinee returned; and that the surface temperature of the right side has
fallen to its normal relation to that of the left, it would give reasonable
hope that the removal of pressure and of the diseased tissue, in which
irritative changes were undoubtedly progressing, will result in a perma-
nent cure.

ROTATION OF OVARIAN TUMORS;

ITS ETIOLOGY, PATHOLOGY, DIAGNo-I- a.M> TKKAT.MI.M

By J. Knowm.ky Thornton, M.B.. CM..

SURGEON TO THE SAMARITAN HOSPITAL, COil8TTLTI.NO 6UROEON TO THE 0B08VEN0R AND
NEW HOSPITALS FOR WOMEN.

The twisting of the ovarian pedicle, from axial rotation of the tumor,
is of great intere>t to the pathologist, both as to its etiology and its
results : and it is a sufficiently common accident to make it of even greater
interest to the physician or general practitioner who is called upon to

358 THORNTON, ROTATION OF OVARIAN TUMORS.

differentiate its symptoms from those of other peritoneal diseases, and to
relieve the great pain t<> which it commonly gives rise. It is, however,
to the practical surgeon that all three must turn for their knowledge of
the subject, and for the cure of the patients. My attention was early
directed to the condition by a very unfortunate case, which I have re-
corded at length in the Transactions of the Pathological Society of London,
and in a paper published in the Medical Times and Gazette more than
ten years ago. The completion of six hundred cases of ovariotomy,
among which I have met with no less than fifty-seven cases of twisted
pedicle, seems to afford a fitting opportunity for giving to the profession
the facts observed.

Rokitansky first drew attention to this subject by a very valuable
paper on "Strangulation of Ovarian Tumors by Rotation," published
in 1865. He described thirteen cases, eight of them met with in the
post-mortem examinations made in fifty-eight cases of ovarian disease —
a highly suggestive percentage, with regard to the mortality of the
complication, when allowed to run its natural course. ' He had previ-
ously called attention to the subject as early as 1841, in the first volume
of his Handbook of Pathological Anatomy. Sir Spencer Wells, in his
second book on Diseases of the Ovaries, refers to Rokitansky's papers and
gives some valuable records of his own experience, and in his more
recent work on Ovarian and Uterine Tumors, page 60, he mentions two
cases in which death took place before operation. He thus describes
the results of rotation: "Congestion, exudation of serum, extravasation
of blood and rupture follow in rapid succession," and again: " If the
rotations are so complete and enduring as to strangulate the arteries,
gangrene is inevitable." I shall have to refer to these passages again
in my concluding remarks. He also points to the danger of intestinal
obstruction as one of the possible results of twisted pedicle, and records
a case of the removal of a dermoid tumor with twisted pedicle, during
pregnancy, with a successful result. This tumor had been carried by
the patient for eighteen years, and through several pregnancies, and was
found at the operation, as in some of my cases to be hereafter recorded,
entirely separated from its pedicle.

Knlb has recorded a case in which a fibroid tumor of the ovary, with
twisted pedicle, caused obstruction of the intestines.

Peatlee, in his work on Ovarian Tumor*, mentions cases in the prac-
tice of V:in Buren and James Crane; Van Buren'i cases were both
fibroid tumors of the ovaries, and in one he operated with success.
Orane'l ii ■ very typical case, the woman being seized with " agony of
pain in the left iliac region " twenty-four hours after labor, and dying
on the fifth day,

uban. so far hack led a case of rapidly fatal intra-

cystic hemorrhage from rotation of an ovarian tumor.

THORNTON, ROTATION OF OVARIAN TUMORS. 359

Wiltshire has the honor of being the first operator who successfully
removed a strangulated ovarian tumor in the acute stage of the acci-
dent; the symptoms came on four days before the operation, the twi^t
was from right to left and the tumor of the right ovary. The patient
recovered. Edwards, of Malta, published a case in The Ixincet in 1861.
The patient was known to have had a tumor during her first gestation.
On the second day after her second labor, she was suddenly seized with
violent pain, and died on the fourth day. At the autopsy, a tumor of
the right side was found, with twisted pedicle; it was of a livid purple
color, and there were patches of extravasated blood in its walls, which
had given way ; there was no peritonitis, and there were no adhesions.

Barnes records a case in the St. Thomas's Hospital Reports, 1870. The
patient was prematurely confined, and died nine days later. At the
autopsy, a dark-colored cyst was found, with a double axial rotation
from right to left. He mentions a second case, in which the symp-
toms were mistaken for those of labor. Both were tumors of the right
side.

Malins published a case in The Lancet for April, 1877 ; the twist was
from within toward the left and over to the right, and had followed
tapping. The tumor was presumably of the right ovary, but it is not
distinctly stated so.

My own paper on " Three Cases Illustrating some of the Various Re-
sults of Rotation of Ovarian Tumors" was published in The Medical
Times and Gazette of July 28, 1877. The three cases there detailed are
the first three in the table which accompanies this paper. I then sug-
d '• that the peristaltic action of the ' intestines may start the pro-
cess,' and that the twist, once started, the pulsations through the cord
thus formed ' would tend to increase it." " I also said : " If the case is
complicated with pregnancy, the fcetal movements may play ' an impor-
tant part.' " We shall see how far the facts brought out by an exami-
nation of the numerous cases in my tables support my suggestions and
those of others to which I am about to refer.

Veit, in 1878, mentions that ><-hr<">der had at that time met with
thirteen cases of twisted pedicle, in ninety-four ovariotomies, a result
very closely corresponding with my own experience, as will be seen by
noting the numbers in the third, fourth and fifth hundreds, though the
proportion in the first, second and sixth is much smaller.

Tait read a paper on the subject before the Obstetrical Society of
London, in 1880, also founded on three cases, and an interesting discus-
sion followed. He advanced the theory that the solid wedge of feces
passing down the rectum was the cause of the rotation ; but to support
his theory, the tumors must all be on the right side, and my table shows
that this is by no means the case. I think it is quite possible, however,
that this may be one of the causes of rotation, and we shall see that an

VOL 96, SO. 4.— OCTOBER. 1888. M

860 THORNTON, ROTATION OF OVARIAN TUMORS.

observation made by Doran, when making a post-mortem in a case of
my own which died from cancer of the rectum, while in the Samaritan
Hospital with ovarian tumor, rather supports Tait's theory.

In the fourth edition of his work on Diseases of the Ovaries, Tail
further discusses the subject at some length, and mentions that he had
thru operated upon nine cases with this complication. His attention
was, like my own, originally called to the subject by an unfortunate
case in which he operated for hernia; the patient died four or five days
afterward, from gangrene of an ovarian cyst with twisted pedicle, and
the autopsy made him doubt whether the symptoms all along had not
been due to the ovarian trouble, rather than to the hernia.

Doran, in his work on Tumors of the Ovary, etc., devotes a whole
chapter to " Twisting of the Pedicle." He thus describes the case
already referred to: "a little artificial distention of the intestine caused
it to press against the tumor so as to push its left side backward, stretch-
ing and twisting the pedicle." There was no twist in this pedicle, but he
found vessels in it blocked with old clot, and it seems probable that the
loading of the rectum caused by the cancerous stricture may have from
time to time caused enough twist to set up clotting and changes in the
vessels. He remarks: "Still I believe that, as a rule, the twisting of
a pedicle is to be explained by the simpler doctrine that the tumor,
pressed upon by the viscera and even the costal cartilages above, and
by the pelvic structures below, but comparatively free laterally and
anteriorly, rotates on its own axis every time that the patient, after
walking or lying on her back, ' turns round and rests on her side.' "
He sums up the results thus: "This complication may cause ' rupture
or sloughing of the tumor, arrest of growth of the tumor through ob-
struction to the vessels of the pedicle, absolute atrophy of the tumor,'
and. lastly, detachment of the tumor from the pedicle, and subsequent
nourishment of its tissues through vascular adhesions." He figures
a very interesting case of my own of complete detachment, Case 282,
and on the next page gives another figure which exactly represent
the condition I noted in Case 384, though it was not drawn from my
specini'ii. M r. Doran has kindly allowed me to reproduce these drawings.

Having thus briefly glanced at the literature of the subject, I will
now proceed to a critical examination of the cases in my own tables, to
see what actual facts they give us, and what probable explanations or
mora doubtful points they suggest.

The first (ad is: that rotation is most oommon during the period of

menstrual activity, two of the youngest patients being nineteen, and the

majority between twenty and forty-five; it is, however, not by any

mfined to this period, for DO less than oine of my patients had

reached or passed the age of fifty, and one was only thirteen and had

r menstruated, A careful examination of my note-books also estab-

THORNTON, ROTATION OF OVARIAN TUMORS.

lishes the fitct that the regularity and the amount of the catamenia are
m>t usually affected, though there are a few marked exceptions, in which
oorrhoea or menorrhagia seems to have been induced. This rather
■uprises me, as I should have expected, especially in the chronic cases,
that the irritation of the ovarian nerves would have made menorrhagia
tin- rule, ami I imagine that the loss of blood into the cyst must, by its
;>ensatory action, prevent this in the majority of the cases.

It is natural to pass from the effect upon menstruation, to that brought
about by the natural amenorrhcea of pregnancy. I have operated during
pregnancy six times, and five of these cases had twisted pedicles; this
shows a very close relation between the two conditions; and when we
examine the column in the tables headed history, we find in it no fewer
than nine other cases (or fourteen in all), in which the acute symptoms
were associated with pregnancy or delivery, beginning commonly shortly
after the latter, or after a miscarriage.

There are also four other cases in which the attack was associated
with menstruation, or with its check by exposure to cold. Thus in
eighteen cases out of fifty-seven, the circulatory phenomena associated
with menstruation and pregnancy seem to be the active agents in pro-
ducing the acute attacks. When we remember how very difficult it is
to extract any facts from some patients, and how especially difficult it is
t«> make them remember even the common time of their periods, much
more to make them associate any special occurrence with the presence of
menstruation, we may reasonably suppose that in many of the other
cases the attack came during or in some connection with the period.

Accidents, direct violence, sudden strain and sudden change of posi-
tion are the determining causes of the attack in eight cases; thus, we
have walking downstairs, catching at a falling box, constant and vio-
lent coughing, sea-sickness, the administration of an enema, sponge
tenting, falling over a hedge and straining at stool during severe con-
stipation. Then, as in my first case, the tapping of the cyst seems to
have precipitated the catastrophe in two other cases, and in two more
it is a possible agent, though the history is imperfect.

There are only eight cases in which the patients did not have, or did
not remember, a sudden attack of pain and more or less severe illness
after it.

With regard to the influence of pregnancy, it is worthy of note that
thirty-six of the fifty-seven patients were married women, a number out
of proportion to that of the married and single cases in the whole >ix
hundred ovariotomies.

It is obvious that the side on which the tumor grows has nothing to
do with rotation, for there are in my tables twenty-eight cases of tumors
of the right ovary and twenty-eight cases of tumors of the left ovary,
and one in which both were involved.

362 THORNTON, ROTATION OF OVARIAN TUMORS.

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366 THORNTON, ROTATION OF OVARIAN TUMORS.

Unfortunately, I have not paid sufficient attention to the direction of
the twist to see if this would help at all in explaining how it is first
started. I have only noted it in nine cases : three were right-side tumors,
and in two the twist was from right to left, and in one from left to right ;
six were left-side tumors, and in five the twist was from left to right
and in one from right to left. It would seem from this small number
of observations that the tumor twists more readily inward and away
from its own side, and this is, I think, borne out by the few observations
recorded by other observers, and is what one would rather expect to be
the case if one considers the position in which a small tumor hangs from
the back of the broad ligament, and the relations of surrounding organs
to it. I think it is not at all improbable that the amount of muscular
tissue contained on the inner side of the pedicle may, by its contrac-
tions, tend to draw the tumor toward the middle, and thus aid a turn in
this direction ; possibly this may explain the acute symptoms so fre-
quently following rapid diminution in the size of the uterus and its firm
contraction, as after miscarriage or labor.

The arteries with their thick walls are chiefly on the inner side of the
pedicle, and if this direction of twist be the common one, it may explain
why so much twisting occurs in some pedicles without complete obstruc-
tion, the softer veins in the outer parts of the pedicle being less severely
pressed upon than the more resistant arteries. I imagine that the
complete obstruction of the pedicle depends greatly upon the thickness
of the tissues in it, apart from its vessels — i. e., upon the amount of
padding round the vessels, a thin pedicle with hardly anything but
vessels being much more liable to complete occlusion. Of course, the
length of the pedicle and amount of play thus allowed to the tumor are
also important factors, any drag upon the vessels after the twist has
started being very likely to finish the obstruction ; indeed, it is the ex-
treme of this condition which cuts through the pedicle and causes those
curious cases of transplanted tumor, some of which will be found in my
tables, ami to which I shall have again to refer.

Khtb has suggested that the alternate filling and emptying of the
bladder ii t he chief predisposing cause of rotation. If this be so, one
would expect the tumors to rotate in the direction of the majority of
my noted cases, the left side of a right tumor being pushed back and
rolled toward ItS '>wn side of the body each time the bladder tills; thus
the habit of allowing the bladder to become greatly distended before
emptying it would become a predisposing cause of rotation.

It i- somewhat difficult to Garry in one's mind exactly what is meant
by twitting from right to left, or via vend, and 1 have, therefore, given
diagramatically the direction of the lines made by the twist in a pedicle

on the ri-ht side, when ^-m from above, ai in an ordinary ovariotomy.
I am Mill inclined to regard my original suggestion, that it is the

THORNTON, ROTATION OF OVARIAN TUMORS. 367

peristaltic action of the intestines which starts the rotation, as the cor-
net one. I recently punctured the intestine on the right side with a
fine trocar, to give temporary relief to an old gentleman dying of ob-
structed intestine, and greatly distended with gas ; after the first rush no
gas came for a time; then the portion of the trocar outside began to
move round in a semi-circle, travelling from right to left, until it reached

Fio. 1.

Right to left. Left to right.

a certain point, when there was an immediate escape of gas, the peris-
talsis ceased and the trocar resumed its former position, the whole pro-
ceeding going on with the regularity of clock-work for a considerable
time, a period of complete rest being followed by a gurgle in the in-
testine, which warned us that the trocar would begin to move. Doubt-
less, a similar regular action goes on in health as the contents of the
bowel move, and, according to the portion of the tumor pressed upon
and the part of the bowel pressing, would be the first impulse to turn,
which each succeeding peristaltic movement would increase, unless the
elasticity of the pedicle was sufficient each time to draw it back into its
original position.

Whatever theory we accept as to the mechanism which starts the
twist, I think we must admit that the shape and regularity or irregu-
larity of the surface of the tumor must have an important bearing, and
this is supported by the relatively large number of dermoid tumors
found in my tables — eight out of fifty-seven ; these tumors very com-
monly have hard projections from their wails upon which the motive
force would naturally gain a purchase. The total number of dermoid
tumors in the six hundred ovariotomies is only forty, or six and a half
per cent., while the number of dermoid tumors among the cases of rota-
tion is over fourteen per cent. I have omitted in the tables certain
columns which will be found in my complete ovariotomy tables, because
I wished to keep the former within reasonable space. Among these
columns is that stating the weight of the tumors; it is of interest to
remark, however, that tumors with twisted pedicles are usually of small
size, thirty-six of them under ten pounds in weight, many of them five
pounds or under, and only eight being twenty pounds or over ; all the

3()3 THORNTON, ROTATION OF OVARIAN TUMORS.

bearers of those, who gave a reliable history, fixing the acute attack
at a period when the tumor was in its early growth. This is only what
one would expect, for when the tumor becomes large enough to distend
the abdominal parietes it would be impossible for any intraperitoneal
forces with which we are acquainted to rotate a tumor thus firmly held.

We now pass from the few facts and plentiful theories as to the
etiology of the condition to its pathological results, which are very
definite. First, we have interference with the circulation ; the firm arte-
ries, resisting pressure, continue to pump in blood, which the yielding
veins cannot return quickly enough, so that congestion with exudation
of serum, rupture of vessels and extravasation of blood, and rapid
enlargement of the cyst result. These processes are accompanied by
acute pain, chiefly referred to the pedicle, and due to the pressure to
which its nerves are subjected, but also in extreme cases extending
over the whole surface of the tumor; also by reflex symptoms, such as
vomiting and collapse, and by fainting and pallor, the result of the
internal hemorrhage. The strong fibrous covering of the tumor pre-
vents rupture of the external vessels, and in the majority of cases con-
fines the effused blood; but if, as sometimes happens, previous inflam-
matory changes in the cyst-wall have caused blocking of vessels and
deficient nutrition of portions of its substance, these, being soft and lacer-
able, give way, and the mixture of ovarian fluid, serum, blood and clot
is poured into the peritoneum. This accident is, as we have seen, often
speedily fatal ; but in many cases, the pedicle vessels being closed by
clot, the hemorrhage ceases, the effused matters, after causing more or
less peritonitis and effusion of parts, are absorbed, and the patient
slowly recovers, till the rent in the cyst heals, and the adhesions affording
a new blood supply, the tumor starts growing again. A glance at the
adhesion column in my tables will show that in the great majority of
the cases extensive adhesions are the rule, but there are a few excep-
tions, due apparently to the twist being only partial, or taking place so
gradually that the tumor is able to accommodate itself to the change
in its blood-supply, and either enlarges very slowly or ceases to grow at
all, and gets smaller from the gradual reabsorption of its fluid con-
tents. Some few cases are on record in which a tumor atrophied and
ceased to lie a cause of trouble in this way. Exactly a fifth of my cases
had no adhesions; several of these were only partially twisted, and in
only one of the non adhesive tumors was the pedicle completely ob-
structed, and in that one there was a very clear history of a gradual
twist, tie- symptoms recurring at each monthly period.

It seems perfectly char that whatever amount of twisting there may
have been going on, it is only when the acute stage is reached that the
peritoneum hecomes Involved and adhe-ioiis take place. Thus, when
Operating, OHO COnld by the nature and strength of the adhesions usually

THORNTON, ROTATION OF OVA KI AN TUMORS. 369

tix pretty marly the length of time which bad passed since the acute
as one can say, this patient hai bad several roeeaw
being guided to this conclusion by the varying condition of the
eztravaaated blood.

The adhesions are pathological in their origin and in their after-
growth, for without them the tendency would be toward atrophy ;
whereas, through them the tumor speedily obtains a fresh blood-supply
and starts into fresh activity. They have also more immediate ill—
eading, in some cases, to discharge of the cyst contents into the
el or bladder, and in others, to fatal obstruction. Then, when
ovariotomy has to be performed, they somewhat, though not greatly,
increase its immediate risks, and also those more remote, such as recur-
of growth and obstruction of intestine.

Fig. •_>

Showing nniYersal nature of adhesion.

The immediate mortality of ovariotomy in these cases is not much, if
at all, in excess of that of any large- number of cases of other nature.
Four only of the fifty-seven died, and two of these deaths were certainly
due to infection of the cyst contents by tapping rather than to the mere
rotation <>r its effects on ovariotomy.

We must now return to the history column, and by its aid study the

diagnosis of rotation. If the patient be known to have an ovarian

tumor before she suffer from any of the symptoms there described,

their appearance should at once put her medical attendant on his

id, and cause him to seek for confirmatory evidence in support of

370 THORNTON, ROTATION OF OVARIAN TUMORS.

the suggestion they make, prepared to advise early ovariotomy if the
diagnosis is strongly probable or certain.

If the presence of the tumor be not suspected before the acute attack,
it may be much more difficult to make a diagnosis, because the patient
will be in such pain that examination is difficult or impossible, and the
peritoneal symptoms may rapidly supervene and mask those more
directly due to the rotation. Any sudden attack of pain in the situ-
ation of either ovary, especially if it occur in connection with men-
struation or pregnancy, should be a ground for a careful bimanual
examination at the earliest possible opportunity, when the tender,
twisted pedicle will very probably be felt to one or the other side of the
uterus. I was able to feel it distinctly before operation in a large
number of my cases, and have no doubt it would have been more
readily detected in others, had they come under my notice while it was
tender, and before it was masked by surrounding adhesions.

The other symptoms which are important in making a diagnosis are
sudden increase in the size of the tumor, usually accompanied by faint-
ness, pallor, quick pulse and other signs of internal hemorrhage. These
symptoms are often accompanied or quickly followed by those of peri-
toneal disturbance, tympanites masking the tumor, nausea or vomiting
of green or bilious fluid and difficulty in passing down the flatus which
has rapidly accumulated in the bowels, from the muscular coat losing
tone as a result of the peritonitis. Sometimes there is hemorrhage from
the uterus, but this is not a constant or even a common symptom. If
any portion of the cyst-wall has become soft and diseased, from the
blocking of vessels already referred to, it will very likely give way,
increasing the peritonitis; then, as this subsides, the tumor will have
become smaller or perhaps have disappeared, with diarrhoea or profuse
How of urine. The illness brought about by this acute stage of the
twist may pass off quickly or may last many weeks; and the nature
and extent of the adhesions probably depend upon the longer or shorter
duration of the peritonitis.

If it were possible to make an immediate diagnosis, I think there can
be no doubt that the proper course would be immediate ovariotomy
before peritonitil sets in; if, however, the symptoms of collapse and
hemorrhage have pasted and those of acute peritonitis become marked
before the surgeon sees the patient, I am certain he will be wise t.> hold
his hand ami let the acute stage pass before performing ovariotomy.

If there is reason to believe that hemorrhage is still going on and the

patient's life is obviously in danger from this cause, all risks must be

performed. Such a case was No. _'l in my table,

but the peritonitil continued and became more general after operation,

thfl patient sinking in forty-one hours from obstruction of the intestines.
more I see of abdominal surgery the more I am convinced that

THORNTON, ROTATION OF OVARIAN TUMORS. 371

operation during acute peritonitis is very dangerous, whereas, in the
subacute or chronic stage, the patient bears operation as well or better
than with a perfectly healthy peritoneum.

There is abundant evidence that rotation of an ovarian tumor is, in
a certain number of cases, an accident immediately dangerous to life;
but so is any operation during acute peritonitis, and the large number
of cases which I here record shows that the majority will get over the
acute attack if kept quiet and properly treated, and may then be oper-
ated upon with as good a chance of success as if the rotation had never
occurred. Most likely, the majority of the cases that die would get
well if the condition was correctly diagnosticated and treated, absolute
rest, ice to the head or to the abdomen to keep down the temperature,
opium to allay pain and control the peritonitis and careful rectal feeding
and stimulation to support the strength being the leading indications.

It is probable that the rotation is generally a slow process, a certain
amount of twisting gradually taking place and causing congestion and
increased growth for some time before some sudden change in the circu-
lation or some mechanical accident causes a complete venous block, and
the arteries still forcing blood into the tumor, the acute stage is reached.

I will now briefly recapitulate the facts which my tables seem to
establish, leaving the theoretical suggestions I have ventured to bring
forward to be confirmed or disproved by further experience:

Rotation of ovarian tumors is of frequent occurrence, Rokitan.-kys
observations on the dead showing that it occurs in over thirteen per
cent., and mine, on the living, that it occurs in about nine and a half
per cent, of all cases of ovarian tumors ; the difference in our figures
being due, 1st, to the fact that early ovariotomy being now the rule, more
tumors are removed before they have a chance of rotating than at the
time he made his observations ; 2d, to the fact that a certain number
of cases will probably die of the complication, and these do not come
into my tables.

It occurs with greater frequency during the period of active menstrual
life than at the two extremes, and more often in married than in single
women.

It is so frequently associated with pregnancy that this condition must
be considered a predisposing cause.

It is also especially apt to occur with dermoid tumors. Adhesions are
the rule whenever the acute stage has been reached, but there are some
few exceptions, and slight twisting does not seem to cause adhesions.

It frequently happens that the circulation throughout the pedicle is
entirely cut off, but a fresh blood-enpply is usually rapidly obtained
through the adhesions. Tumors of the right and left ovaries are equally
liable to rotation, and may twist either to the right or to the left, but
the turn from right to left seems most common on the right side, and
from left to right on the left side.

372 THORNTON, ROTATION OF OVARIAN TUMORS.

There is no certain evidence as to the motor force which first starts
the rotation, and it seems improbable that this can ever be exactly set-
tled, but probably different causes may act in different cases.

The steps of the process seem to be: gradual rotation, without symp-
toms or serious pathological change, then sudden serious symptoms, with
rapid increase of the tumor, then decrease or complete cessation of
growth, followed, sooner or later, by renewed activity, as the circulation
through the adhesions becomes free enough to replace the diminution or
arrest of that through the pedicle.

The extreme pathological result of rotation is division of the pedicle
ami transplantation of the tumor ; Cases 7, 14, 22 and 26, in the accom-
panying table, illustrate this condition, and it will be observed that all
the tumors are dermoids ; the majority of cases of transplantation
recorded by other observers are also dermoid, so that it is clear that the
dermoids are not only, as I have pointed out, specially liable to rotate,
but are also specially liable to such extreme rotation that the pedicle is-
divided.

Fig. 3. Fio. 4.

Fig. ".— I>iti! d cy»t twisted off it* pedicle and receiving its TMcuUr supply from the adherent
omentum.

Fig. 4. — Stuni ' hmIicU- <> tiiiimr represented in Fig. 3.

I haw said that the ex t mm- pathological result is transplantation,
and I haw air. ady quoted the opinion of Sir Spencer Wells, that if the
arteries are strangulated, gangrene is inevitable; but surely gangrene of
the tumor would be a nioiv extreme pathological state than transplan-
tation and rem wed growth. Yes; but I deny that gangrene ever results
from twisting of an ovarian pedicle, unless there is some element intro-
duced from without to cause death of the tissues, as in Case No. 1, in my
table. Other writers, notal.lv Tail, have followed Wells in speaking
of rotation leading to gangrene; if this were true, the mortality from

THORNTON, ROTATION uF OVARIAN TUMORS. 373

rotation would be fiur greater than it has been shown to be, and I cer-
tainly should not have been able to record titty-seven cases with only
four deaths. Even in the cases in which sudden and complete obstruc-
tion of the arterial and venous circulation takes place, gangrene does
not follow, because the tumor is enclosed in that great lymph- -
the peritoneum, and cut off from the external agencies which cause
gangrene in a limb or external part under similar conditions of ob-
structed circulation. The tumor may be black and discolored and full
of blood-clots, but it is not gangrenous or sloughing; its condition is one
of acute inflammation which rapidly spreads from its peritoneal covering
to the other peritoneal surfaces in contact with it, and the peritonitis
may be so severe as to cause the death of the patient ; but to say that
the tumor becomes gangrenous and kills the patient is contrary to all
we know at the present day of the pathology of death of tissue in the
living body. Blood-clot contains, in a marked degree, the vital ele-
ments which resist putrefactive changes and death, and its presence in
large quantity in these rotated tumors is one of the greatest safeguards
against their death, giving time for the reestablish ment of the circulation
through the rapidly adhering peritoneal surfaces.

conceivable that in a patient with very little vitality or with a very
depraved condition of the blood, rapid growth of putrefactive organisms
in the tumor might lead to real gangrene or sloughing, but no such case
has yet been recorded, and I think it is extremely improbable that the
organisms could live in such a highly vascular and highly organized
part as an ovarian tumor, and in order that these organisms may act at
the moment of complete strangulation, they must already be occupying
the ground. Of course, in cysts that have been tapped, and into which
organisms may thus have gained access from without, the conditions are
altogether changed, and then, as in my case, if acute strangulation
follow, real gangrene may result. It is also possible that the Fallopian
tube may bring the elements of septic change into contact with a stran-
gulated ovarian cyst, and produce a true gangrene, and this may be
the pathology of some of the cases fatal after delivery or abortion ; but
to prove the truth of the theory we must have careful microscopic
examination of the tissues in such a case, showing the presence of the
cocci, and cultivation experiments also, if we are to be sure that the
cocci are those known to produce poisonous change in the blood. I
know of no such demonstration having yet been made.

Bibliography.

Rok&antky : Zeitschrift der K. K. Gesellschaft der Aertze in WIen, 1865.

ber die Strangulation von Ovariai Tumoral durch Achsendrehung."

•ases of the Ovaries. 1872, p. 88 ; Ovarian and Uterine

Tumors, 1882, p. 60. Klob: Patholoeiache Anatomic der Weiblischea Sexual

gane, Wien, 1864. I arian Tumors, 1873, p. 80. Van B>

374 DUHRING, TYPICAL IMPETIGO SIMPLEX.

New York Journal of Medicine, March, 1850, and March, 1851. Sterne:
American Medical Monthly, April, 1861, p. 375. Patruben : Desterreichisches
Z.itschriit fur practische Heilkunde, 1855. Wiltshire: Transactions of the
Pathological Society of London, 1868, p. 295. Edwards: Lancet, vol. ii. p.
336,1861. Barnes: St. Thomas's Hospital Reports, 1870. Malins: Lancet,
1877, vol. i. p. 529. Knowsley Thornton : Transactions of the Pathological
Society of London, vol.1876, xxvii. p. 212; Medical Times and Gazette,
1877, vol. ii. p. 82. Veit: Archiv fur Gynakologie, 1878. Tait: Transactions
of the Obstetrical Society of London, 1880, vol. xxxi. p. 86 ; Diseases of the
Ovaries, 1883, p. 2!»4. Varan: Tumors of the Ovary, London, 1884, p. 118;
Gynecological Operations, 1887, p. 176.

TWO CASES OF TYPICAL IMPETIGO SIMPLEX.'
By Louis A. Duhring, M.D.,

PROFESSOR Or SKIN DISEASES IN THE UNIVER8ITY OF PENNSYLVANIA .

Considerable scepticism obtains in the minds of some eminent der-
matologists concerning the existence of a distinct disease of the skin
entitled to the name impetigo. They, for the most part, regard all such
manifestations as forms of pustular eczema, as impetigo contagiosa or
as lesions due to parasites or to external irritants. Recently, Dr. T.
Colcott Fox, of London, in his annual report of the Department for
Skin Diseases in the Westminster Hospital,2 states that he does not
recognize impetigo ; and that if such an affection does exist, he has
doubtless confounded it with impetigo contagiosa. In view of these
facts and that I am quoted by Dr. Fox as advocating the existence of
this disease, a brief account of two cases may prove of interest. They
may be regarded as typical examples of this dermatosis. Impetigo must
be looked upon as one of the rarer cutaneous manifestations, and, it may
be added, I have met with but few instances in which the features were
so sharply defined as in the present cases. The well-known so-called
eczema impetiginosum, as well as impetigo contagiosa and ecthyma, are
all, of course, to be excluded. To these diseases I shall refer again.

The notes of the cases, it may be stated, were made at the date of
observation.

Case I. — The first is that of a boy, aged four years, a well-nourished,
stout, hearty-looking child. The mother states that he has always here-
tofore enjoyed excellent health, and that this is the first disease of the
skin he has ever shown. It began two weeks ago with slight itching,
which was loon followed by "whitish lumps, like hives;" snortly after
this yellowish-white lesions — pustules— appeared, a few at a time. " last-
ing several days and drying up." They formed rapidly, from three to
live days sufficing to arrive at maturity. There were slighl t'.vcrish

• Ron.1 tM.for* the AnartoM P«rmatological Association, at the Eleventh Annual Meeting.
« Vol. Ii., UadOB, 1M6.

PURRING, TYPICAL IMPETIGO SIMPLEX. 375

symptoms in the beginning, but not any since, although the child is
still restless and scratches himself at night The bowels are somewhat
constipated hut the appetite remains good.

At the present time there exist about two dozen lesions, situated
mostly upon the fingers, toes and legs. They are typical pustules, and
vary in size from small to large split peas. In form they are uniformly
semi-globular, or dome-shaped, and are raised about a line above the
surrounding healthy skin. In no instance are they either acuminated
or umbilicated. They are firm ; have thick walls ; and are tensely dis-
tended. In passing the hand over the surface they can be readily
detected as firm, distinctly defined elevations. They are mostly of a
pale sulphur-yellow or straw color, but in some instances are whitish-
yellow, and are seated upon extensive bright reddish, highly inflam-
matory, non-indurated bases. They are, moreover, discrete, and manifest
no tendency either to aggregate or to group. The regions involved are
the neck, arras, hands, hips, thighs, legs and feet. The face and scalp
remain free. There is one large and conspicuous lesion on the dorsum
of the foot.

The case was seen on several occasions subsequently, the lesions each
time showing signs of rapid involution. Crusts, somewhat friable, yel-
lowish in color, formed, and in the course of a few days dropped off,
leaving a circumscribed reddened surface or spot, which in a short time
disappeared. The process showed itself to be benign and superficial in
character, and ran its course in from two to three weeks. No treatment,
either local or internal, was employed.

Case II. — The second case is that of a boy, likewise four years of age,
stout, ruddy, and healthy looking, who was brought to me with a dis-
seminated, discrete, distinctly pustular eruption, which had appeared
seven days before. The mother stated that the child was in good general
health, and that digestion and the bowels were in proper order. The
skin disease had manifested itself first about the face, then about the
hands. At present it consists of twenty or thirty disseminated, some
few acuminated, but mostly serai-globular, small pea-sized, inflammatory
pustules with slight areolae. They are yellowish, opaque, and, for the
most part, without signs of crust. The older lesions are whitish, with
only faintly marked areolae, and are sharply defined and conspicuous.
They occur about the eyebrows, eyelids, bridge and side of the nose, and
over the temples ; also on both hands, including the fingers, which are
swollen, and it is here that the disease shows itself most markedly. The
backs of the hands, palms and fingers are studded with numerous, dis-
crete lesions, pea and bean sized, circumscribed and semi-globular, and are
surrounded with defined areolse. In form they are rounded or ovoidal,
and they are distinctly pustular, being opaque and of a whitish-yellow
color. They are elevated about a line above the surrounding healthy
skin ; and are, for the most part, tensely distended, firm to the touch, have
thick walls, show no tendency to rupture, and at a distance resemble in
appearance small whitish, sugar " mint drops" stuck on the skin. There
is no itching, but the hands feel sore.

The child was seen on several occasions during the following week, and
but few new lesions appeared. The older ones became larger, whiter,
and crusted into rather friable, yellowish crusts, while some few became
flaccid, and through contact had been ruptured, discharging contents
streaked with blood. In addition to the impetigo a slight herpes zoster

vol. 96, no. 4.— ootobm, 1888. 25

376 DUHRING, TYPICAL IMPETIGO SIMPLEX.

dorso-pectoralis now made its appearance, which ran a benign and rapid
course. The treatment had from the beginning been expectant, and the
disease pursued a course ending in spontaneous cure in from two to three
weeks.

In both of these cases striking pictures are shown, representing a
clearly defined, distinctive disease, the lesions being peculiar pustules
which cannot be confounded with those of other pustular diseases. They
begin as pustules and run their course as such. The process is a simple
and benign one ; superficial ; leaves only a slight pigmentation, which
soon passes away ; and in both instances cited ran an acute and definite
course. The disease is not contagious. It possesses none of the features
and characteristics of eczema, the lesions differing in many respects from
those of pustular eczema, the " eczema impetiginodes " of older writers.
They are discrete, with no disposition to coalesce ; are variable in size,
for the most part large, the size of a pea, or, occasionally, even a finger-
nail. They differ from eczematous pustules, moreover, in possessing
thick, firm, resisting walls, with no tendency to rupture, or to break down
and discharge ; finally, in being disseminated and in occupying the
general surface with no disposition to localize.

From impetigo contagiosa the lesions differ in being from the begin-
ning much more distinctly pustular ; in having firmer and thicker walls :
and in presenting larger and more bulky crusts. The history of con-
tagion is also wanting. It may further be stated, that there is also a
marked difference between these lesions and those of simple ecthyma,
which are flatter and tend to spread more evidently on the circumfer-
ence ; yellower, showing a more active pyogenic nature ; and more
hemorrhagic, indicating a debilitated state of the tissues, the subsequent
crust being brownish. In looking into the etiology of the two diseases
we find impetigo to occur, as a rule, in healthy individuals, and ecthyma
in the broken-down or cachectic.

Idiopathic simple impetigo must also be distinguished from those
pustular lesions which not infrequently arise as the result of external
irritants and from animal parasites. These causes play no part in the
form of disease under discussion. The disease which I have endeavored
to illustrate by the two cases just reported, corresponds to the " impetigo
sparea" of Bateman,1 Wilson,' and Hillairet and Gaucher,' and others,
and in this country has been described by myself,* Hyde',6 Roltin-
Bookley' and Van Harlingen.'

1 Practical Synopsis of Cutaneous Diseases. London.

• Disease* of the Skin. London, 1867. * Mai. de la Pean. Pari*, 1886.

< Treatise on Skin Diseases, 3d edition. Philadelphia, 1882.

» Disease* of the Skin. Philadelphia, 18S3. « Manual of Dermatology. New Y. i

1 Manual of Diseases i.f the Skin. New York, 1881 • Handbook of Skin Disease*. Phil*

GRIFFITH, FRIEDREICH'S ATAXIA. 377

A ( «»N TRIBUTION TO THE STUDY OF FRIEDREICH'S ATAXIA.1
By J. P. Crozer Griffith, M.D.,

ASSISTANT PHYSICIAN TO THE HOSPITAL Or THE UNIVERSITY OF PENNSYLVANIA ; PATHOLOGIST TO THE
PRESBYTEUIAN HOSPITAL.

The definition given by Friedreich, which suited well the cases
reported by him, needs considerable modification in order to accord
with our present knowledge of the disease, and might read as follows :

Friedreich's ataxia is a chronic, systemic inflammatory degeneration
of the spinal cord, developing usually in infancy or childhood, in cases
in which there has probably been an arrest of development of the cord
during foetal life ; this being the result of some hereditary predisposi-
tion. It is situated chiefly in the posterior columns, the lateral and
cerebellar tracts and the columns of Clarke, though other parts of the
white and gray matter are very commonly somewhat affected, and the
sclerosis extends slightly into the medulla. The affection is character-
ized clinically by a disturbance of the coordination of the bodily move-
ments, developing gradually, advancing from below upward and finally
involving the organs of speech. Curvature of the spine, talipes, vertigo
and nystagmus are frequent. The patellar reflex is nearly always absent.
Paralysis and slight sensory disturbances are not uncommon in advanced
cases. Trophic, vasomotor and visceral affections are unusual, and any
involvement of intellect is probably accidental.

The cases under my observation are briefly as follows :

Case I. — Sadie T., aet. 23, single. Family history negative, except
that the brother was affected by the same disease. The patient was
well until 10 years of age, when an unsteadiness of the hands and of
the gait appeared, not at all like chorea. After typhoid fever and
measles, a few months later, the ataxia was so much worse that the
patient was unable to walk without crutches, though the incoordination
of the hands was much the same. The disease steadily grew worse; at
16 years the patient was unable to walk at all, or even to sit upright,
and speech became involved.

■nt condition. August, 1887. The patient can barely move the legs
at all. There is slight talipes e<uiino-valgus of both feet; no atrophy
of the legs ; no patellar reflex. There is some scoliosis of the dorsal
region. The grasp is strong, but claw-like; the fingers are held flexed ;
there is no tremor, but a slow ataxic movement, resembling athetosis,
appears while the hands are lying passively in the lap. On voluntary
effort great incoordination of the hands develop, not increased by closing
the eyes. The muscles of the arms are large and strong. There is a
slight jerking motion of the head, but no true tremor ; the speech is
irregular and jerky, and a very slight and inconstant nystagmus on

1 Based upon an analysis of 143 cases, collect >d and tabulated by the author in the Transactions of
the College of Physicians of Philadelphia for 1888.

378 Griffith, Friedreich's ataxia.

extreme lateral motion can be detected. The eye-ground and the tho-
racic and abdominal viscera appear to be normal. There is no sensory
affection, except the occasional presence of a girdle sensation. The
intellect is normal.

Case II. — George T., set. 21, single, brother of the last case. At the
age of two years he suffered from some acute nervous disease, probably
anterior poliomyelitis, leaving him somewhat lame, and with the left
leg and thigh considerably wasted and weakened. When 9 years old
he had measles, followed by pneumonia, and on recovery was unable to
walk without crutches or to sit erect, though the upper extremities
remained uninvolved. The ability to walk was partially regained, but
the disease still progressed, and at 18 the arms became involved. There
is sometimes involuntary spasm of the right leg at night.

/' <ent condition, August, 1887. The left leg is atrophied and power-
less ; the muscles of the right leg not wasted, but the muscular power
decidedly diminished. The knee-jerk is abolished ; there is marked
ataxia of the legs when the patient is supported on them ; the back is
bent to the right. The muscles of the arms are unusually well developed
and the grip powerful. There is marked ataxia of the arms and hands
on voluntary movement ; not increased by closing the eyes. The head
has a slight ataxic movement, the speech is a little jerky, there is slight
nystagmus on lateral motion. The eye-ground and the thoracic and
abdominal viscera are normal. The only affections of sensation are a
slight diminution of cutaneous sensibility in the upper and lower
extremities and a decided involvement of the muscle sense in the latter
region.

Case III. — Annie C, set. 26, single. Family healthy, except that a
brother died of the same disease at the age of 9 years. The patient had
scarlet fever at 9 years of age, and after recovery appeared to be weak in
the legs, and to have a staggering gait. This gradually increased until at
16 years she could not walk at all. At 22 weakness in the arms appeared.
It is not known at what date the affection of speech developed. She com-
plains sometimes of difficulty in swallowing, and of spasmodic contrac-
tion of the legs at night.

Present condition, August, 1887. The patient is unable to sit erect,
and can move the legs but little. There is slight talipes equino-valgus
and dorsal flexion of the toes. The muscles of the lower extremities are
but little atrophied ; the knee-jerk is abolished. The vertebral columu
exhibits lateral curvature. The hands are claw-like and their move-
ments very ataxic, though when at rest they lie in the lap without
motion. The ataxia is not notably worse when the eyes are closed. The
grip is fairly good, but infantile; the muscles of the arms somewhat
wasted. There is a slight tremor of the tongue, a trembling motion of
the bead, particularly on talking or on excitement, and alight nystag-
mus, but the eye-grounds are normal. Speech is slow and somewhat
scanning. Affections of the thoracic and abdominal organs and of the
intellect are absent. Tactile sensibility is evidently diminished, but
sensation is normal in other respects.

Dr. \Y. ('. Warren, of Waterford, Mississippi, has sent me the notei
of 4 cases, 3 of which were very briefly reported some years ago. A
short abstract of them is as follows : The father of the family is of a

GRIFFITH, FRIEDREICH'S ATAXIA. 379

iutvoub disposition, but in other respects the family history is negative.
In each of the first 3 patients the disease began at the age of 8 years,
with staggering, noticed only when first rising in the morning and
disappearini: later. The unsteadiness after a time became permanent,
and the affection next involved the arms, producing marked ataxia, with
a tendency to choreiform movements. In the oldest child, Nannie W.,
now aged 29, the power of walking was lost after a severe attack of
bilious remittent fever at 13. Affection of speech began at 23, making
it now almost totally unintelligible. There is slight trembling of the
tongue, curvature of the spine, painless spasms of the leg, no nystagmus,
and possibly slight affection of intellect, as the patient cries almost
constantly without known cause. The lower and upper extremities are
nearly powerless and held flexed ; the muscles, especially the extensors,
decidedly atrophied. The knee-jerks are absent, talipes equinus present ;
there is no definite affection of sensation ; the pulse is persistently rapid
and small. There is vertigo and some incontinence of urine. The symp-
toms of the second patient, Thomas W., aged 17, resemble those of his
sister, though not advanced to so great a degree. There is, moreover,
no vertigo or trembling of the tongue ; speech is only slightly slow ; the
intellect is normal ; and the ability to move the arms and legs — though
not to walk — is still retained, while all movements become much more
ataxic on closing the eyes. The surface of the body is cold. Robert W.,
aged 15, is less diseased than his brother, in that speech is still unaffected,
and the ability to walk by holding to the furniture is still preserved.
There is, however, decided vertigo. The last patient, Nettie W., aged 8
years, is only beginning to show evidences of the disease. Since 6 years
of age it has been noticed that she staggers when rising in the morning,
and only after some effort and repeated balancings with outstretched
arms, can she succeed in preserving her equilibrium. After a little ex-
ercise this unsteadiness disappears. There are as yet no other symptoms,
except that the patellar reflexes are diminished.

BJBXOBT. — As regards, now, the history of the disorder, Friedreich
reported the first 6 cases in 1863, and 3 more in 1876. Up to the close
of 1876 11 others had been described, making 20 in all. By the end of
1882 the number had reached 47, and now equals 143. These are divided
among authors as follows: Friedreich, 9; Carre, 1 ; Bradbury, 1 ; Car-
penter, 2 ; Kellogg, 2 ; Dreschfeld, 3 ; Kahler and Pick, 1 ; Schmid. _' :
igmnller, 2; Hollis, 1 ; Gowers, 5 ; Brousse, 1 ; Hammond, 6; Cole-
man, 3 ; Warren, 4 ; Leubuscher, 1 ; Power, 1 ; Quincke and Riiti-
meyer, 2 ; Riitimeyt-r, 7 ; Jakubowitsch, 1 ; Erlenmeyer, 1 ; Wiille, 2 ;
Teissier. 2 : Muk>,4; Ma<salongo, 2; Charcot, 2; Botkin, 1 ; Ormerod,
10; Buzzard, 1 ; Fowler, 3 ; Fazio, 1 ; Vizioli, 11 ; Palma, 1 ; Seguin,
-:nkler,o; Smith, 5; Putnam. 2; Prince, 1 ; Fellows, 1 ; MacAlister»
1 ; Fagge, 1 ; Descroizilles, 1 ; Bury, 4 ; Galassi, 1 ; Erlicki and Ry-

380 GRIFFITH, FRIEDREICH'S ATAXIA.

balkin, 1 ; Glynn, 1 ; Freyer, 3 ; Blocq, 1 ; Stintzing, 3 ; Ferrier, 1 ;
Mastin, 3 ; Mendel, 1 ; Shattuck, 1 ; Joffroy, 1 ; Osier, 1 ; Griffith, 3.
Besides these there are upward of 57 cases occurring among the brothers
and sisters or other relatives, but not under professional observation.
Many of these were undoubtedly instances of Friedreich's ataxia.

Name. — The affection has been variously designated as " hereditary
ataxia " [Friedreich], " congenital ataxia " [Mastin], " generic ataxia "
[Smith], " family ataxia " [Fere] and " Friedreich's disease " [Brousse].
The serious objection to the first four titles is that they are not always
applicable, and express conditions as necessary, which are not always
fulfilled. Even the best of them, "family ataxia," is not suitable, for
though the 143 cases are divided among only 71 families, there are 24
instances in which but 1 child was affected. The last of the four titles is
most commonly employed, and would be the best were it not that para-
myoclonus multiplex is also called " Friedreich's disease." To avoid all
confusion, I much prefer the name " Friedreich's ataxia," which desig-
nates the most prominent feature, and yet imposes no limitations to be
violated ; and though it may be objectionable in the using of an author's
name, it seems the best that can be chosen in the present state of our
knowledge.

Etiology. — Heredity. Friedreich's ataxia is essentially one of the
hereditary diseases, but the adjective must be taken in the broad sense
on which Mobius insists. Direct similar inheritance of the disease itself,
or of some form of ataxia, is reported in only 33 cases in 16 families of
brothers and sisters, and most of these are very doubtful examples of it.
Thus Riitimeyer reports 8 cases in 4 families of cousins, whose great-
great-great-grandfather was reputed to have had an ataxic gait. Other
instances are described by Brousse, Carre, Botkin, Mastin, Bradbury
and others; but only in the cases recorded by Vizioli was there an
undoubted example, confirmed by professional observation, of children
with Friedreich's ataxia, springing from a father with the same ahYc-
tion. The patients of Smith are probably another instance of this.
Polymorphic inheritance— in which there have been other neuropathies,
alcoholism, tuberculosis, syphilis, consanguinity, etc., in the family — has
in some respects exercised a much more powerful influence in the pro-
duction of Friedreich's ataxia. Great nervousness or neuropathies, other
than the affection in question, are reported in 58 cases; sometimes in the
parent! only, often in the grandparents, uncles or aunts as well ; and
their influence is undoubted. Friedreich thought that alcoholism had a
strongly predisposing action, since it was present in the parents of 6 of
his 9 cases ; but its influence has been greatly overrated. It is reported
present in the parents of only 31 cases ; and absent in the parents, but
present in other relatives, of 13 others; but in 7 cases alone was it the
only hereditary prediepooiag cause discovered ; and it may have been but

GRIFFITH, FRIEDREICH'S ATAXIA. 381

incidence here. Tuberculosis has virtually no influence, except as it
debilitates the constitution of the progenitors. The same is true of syphilis,
which is mentioned as possibly present in but 2 families. The case of
Pal ma's is interesting : of 2 children of a phthisical mother, suckled by
her, one died of phthisis, the other developed Friedreich's ataxia; the
other children, fed by a wet-nurse, enjoyed good health. Consanguinity
is reported in 4 families, and in 3 of them seems to have been the active
predisposing cause.

Among the brothers and sisters of cases reported, there have some-
times existed conditions pointing to the existence of an inherited family
taint or tendency t<> the disease. Thus there were 31 other children re-
puted ataxic in JO families, but not seen by a physician. Certain other
icious conditions were present in 13 families ; such as stillbirths,
early deaths, feeble reflexes, lack of moral sense, phthisis, etc.

Age. The predisposing influence of aire in Friedreich's ataxia is
shown by the fact that in over one-quarter of the reported cases the first
svniptoms were perceived before the age of 6 years; and in over one-
half before the age of 11 years. In at least 15 cases the disease began
in infancy, and in not more than 25 did it develop after 16 years of age.
The disease has attacked rather more of the male sex ; the num-
bers being 86 males and 57 females.

Acute tfitrwsfis The influence of acute, and usually febrile, diseases in
precipitating the onset of Freidreich's ataxia is seen in 20 cases. As a
rule, the symptoms of the nervous affection appeared immediately on
recovery from the acute disease, but in a few instances their development
was delayed so long (two years after smallpox, in some of Musso's cases)
that the causal relation appears doubtful.

Clinical Histoky. — The disease usually begins with weakness and
unsteadiness of the lower extremities, and an oscillating, staggering gait,
with frequent falls. Very exceptionally there are other symptoms pre-
ceding or attending this ; such as eclampsia, vertigo, pain in various
parts, curvature of the spine, choreiform movements, dorsal flexion of
the toes, palpitation of the heart, gastric disturbance, etc. These are
probably often accidental ; and disregarding them it appears that the
lower extremities were first attacked in 114 of the 143 cases. In 10 in-
stances, the arms, and in 8, the arms and speech were involved simul-
taneously with the legs. In 2 cases the legs and speech were first
attacked, and in 2, the arms alone. The average lapse of time, however,
before the upper extremities became ataxic is 6 years, as far as statistics
allow of calculation ; but the range of variation is very great. Thus in
one of Dreschfeld's cases, the interval was 20 years, and in one of my
own, 17 years. Ataxic movements of the head and trunk may appear
with the affection of the arms or later. The appearance of bulbar
symptoms— the affection of speech being usually the first — averaged

382 GRIFFITH, FRIEDREICH'S ATAXIA.

only H years later than the incoordination of the arms in 31 cases in
which the time of the development of both classes was accurately stated,
and the variation was not great. In 18 of these, both classes of symp-
toms developed at the same time. As the disease advances there may
appear more or less paralysis, muscular atrophy, talipes and other con-
tractures, curvature of the spine and, possibly, affections of sensation.
The patient may become unable to walk, and speech may be almost un-
intelligible. Finally death ensues from asthenia or, oftener, from some
intercurrent disease. The influence of acute, and usually infectious, dis-
eases in accelerating the course of the disease was seen 14 times in 13
patients, 5 of whom lost the power of unassisted locomotion during the
acute illness. The same result followed parturition in one of Fried-
reich's cases.

Symptoms. — Ataxia. Motor ataxia of the lower extremities is directly
stated to have been present in 128 cases, and in others, as in some of
those of Hammond, it is as directly implied. Freyer states distinctly that
there was no ataxia in his patient, in whom, however, the disease was
only beginning. The incoordination was increased by closing the eyes
in 34 cases, and not increased in 19. The gait is only in a few instances
described as like that of tabes. By far more characteristic of Fried-
reich's ataxia is an " oscillating " gait ; " like that of a drunken man,"
as it is sometimes described. Musso speaks of the gait as exhibiting a
lateral projection of the feet, instead of the forward propulsion seen in
tabes. Ataxic station is expressly mentioned or implied in 73 cases,
and was undoubtedly present in many more. Romberg's symptom was
absent in 10 of these, and present in 49. Ataxia on motion of the upper
extremities is reported in 111 cases, in 21 of which it was increased by
closing the eyes, and in 26 not increased. The incoordination is usually
very well marked, so that simple as well as more delicate movements be-
come almost impossible. Prehension is often peculiar, the hand being
spread like a claw.

Muscle sense might well be considered in connection with Romberg's
symptom did space permit. Comparison between the two in the reports
of cases goes to show that there is no connection between them ; since in
at least one-half the cases in which the muscle sense was normal, as
tested by weights, etc., Romberg's symptom was present, and in other
instances in which the former was diminished the latter was absent

Static ataxia, the ataxia of quiet action, the force required to hold
any part of the body quiet when unsupported, is claimed by Chatvot to
be characteristic of Friedreich's ataxia, and absent in tabes. Statk
show that this author and Ormerod are correct in stating it to be one of
the later symptoms, and (mite common in advanced cases, though it is
probably oftener absent than present. It may be seen in athetoid move-
ments of the hand, or as slow, waving motions of the arms when held

GRIFFITH, FRIEDREICH'S ATAXIA. 383

outstretched, or even as choreiform movements. Static ataxia of the
head is quite frequent; shown by an irregular oscillation, either con-
stant or only when the patient is under some excitement. A nodding
of the head is sometimes seen ; " like one going to sleep," as Friedreich
has described it in one of his patients. Similar ataxic movements of
the trunk are reported in a number of cases.

Tremor of some part of the body is found referred to in 8 instances,
but is probably in most of them to be attributed to static ataxia. Only
in Glynn's case was there anything which at all resembled the inten-
tion-tremor of multiple sclerosis.

Choreiform movements, referred to in 17 instances, are likewise, as a
rule, only the evidences of static ataxia; being recognized by most re-
porters as such. They have usually been seen in the limbs, but in 6
cases, grimaces and twitchings of the face are alluded to. Signs of
chorea have appeared as one of the earliest or even initial symptoms in
a few cases, but statistics do not uphold the view of Pitt that the disease
is usually ushered in in this way.

Spasmodic contraction of the muscles is reported in 21 cases. These
occur usually iu the lower extremities when the patient is sitting or
lying in bed, and may or may not be painful. Spasm was also seen in
the face in Fagge's patient, often drawing the mouth into a meaningless
smile; while Botkin's case exhibited grinding of the teeth.

Parahftu is a common feature, though more usual in advanced cases.
I: is stated to have been present in 56 patients, and undoubtedly oc-
curred in many others. The so-called paralysis early in the disease is
generally merely a manifestation of incoordination. The rate of progress
and the degree of paralysis are very variable. One of Vizioli's patients
reached a state of complete immobility after suffering from the disease
for over 40 years, while in Kahler and Pick's patient, power was nearly
gone after 8 years. On the other hand, in one of Friedreich's cases there
was no paralysis after the disease had lasted 24 years.

ili without crutches or assistance from some person de-
veloped in 54 instances. It depends oftener on incoordination than on
paralysis, since in 10 of the cases it is said that there was no pa rah
and the designation was certainly wrongly applied in many of the re-
maining. Some patients had never walked; while others retained the
power for over 20 years.

we* are usually among the later symptoms, and are chiefly
represented by talipes. This was present in 27 cases, and was of various
kinds, though usually equinus and equino-varus. Dorsal flexion of all
or of some of the toes is reported in a number of instances. Contractures
of some of the fingers or of the hands or arms are very exceptionally
present. Curvature of the spine, usually lateral, and considered by
Rutimeyer to be a form of contracture, developed quite frequently (57

384 Griffith, Friedreich's ataxia.

eases) as the disease advanced ; and though it has in a few instances
been observed before other symptoms appeared, its occurrence may have
been accidental.

Electrical contractility has not been sufficiently studied to reveal any-
thing of moment. In most cases, when tested, it was found normal, in
a few, diminished, in still fewer, increased, and in 3, the reaction of
degeneration was present.

Reflexes. — The abolition of the patellar reflex is a very early symptom,
as it is a very constant one. It has been reported in 91 instances, and
in 30 no observation on it was made. The abolition does not, however,
always occur, since the knee jerk was merely much diminished in 7 cases,
diminished in 2, normal in 6, normal or exaggerated in 1, and exagge-
rated in 6. This exaggeration does not necessarily exclude the presence
of Friedreich's ataxia, since 2 of the cases exhibiting it belong to 2 of
the most typical family groups of the disease : viz., those of Vizioli and
of Musso. The knee-jerk will not be abolished unless the lumbar
enlargement be involved, and it is easily conceivable that this involve-
ment might fail to occur in undoubted instances of the affection.

The presence of ankle clonus in 2 instances of Friedreich's ataxia
must be considered entirely anomalous. The cutaneous reflexes were
usually normal, as far as tested ; but sometimes diminished, and rarely
increased.

Of trophic symptoms, the most important is muscular atrophy, which
is comparatively unusual, even when paralysis is decided. It was well
marked in 11 cases, and slight in 24; affecting the lower extremities
more than the upper. Other trophic changes occur with the greatest
rarity, and are possibly accidental.

Vaso-motor affections are chiefly represented by coldness and blueness
of the feet (19 cases).

Sensory symptoms are rather noted by their insignificance. Pain of
some sort, initial or among the early symptoms, is reported present in
22 cases, and absent in 79, and was usually slight and often probably
accidental. Rarely it has been of greater moment, but the absence of
the severe initial lancinating pain of tabes is one of the most character-
istic phenomena. Pain after the disease is well under way is compara-
tively more common, though only observed in 47 patients, often slight
and probably often unconnected with the disease. Even at this stage
lancinating pain is almost unknown. Cutaneous sensibility is at times
diminished (47 cases) but exceptionally increased. The diminution has
usually been very slight and often questionable, but sometimes it is vary
well marked, as in one of Stintzing's cases, in which there was total
anaesthesia of the lower extremities. Panesthesias of all forms an- rare :
girdle sensation, the oommoneet, being referred to in but 8 instances,
in one-half of which it was .-light.

GRIFFITH, FRIEDREICH'S ATAXIA. 385

Affection of speech is one of the most characteristic of the bulbar
symptoms. It is reported in 1<>7 cases, and would doubtless have
developed in many or all of the remaining. It is frequently character-
ized 1>\ a jerky, moderately rapid articulation, interrupted by sudden
and irregular pauses, often between the syllables — a variety which
Friedreich described as " ataxia of speech." Speech may be typically
scanning, or simply slow, or confluent, etc., and may become quite unin-
telligible.

The tongue not infrequently (24 cases) exhibits a fibrillary tremor or,
LeM often, a more general twitching or curling. Mastication and deglu-
tition are only exceptionally interfered with. There was difficulty in
niing the taliva in the mouth in a few instances. The face has often
an expressionless appearance, giving the false impression of deficient
intellect.

Eye. — Strabismus is reported in 8 cases, but may have been only
accidental ; diplopia and blepharospasm are referred to in a few
instances; partial atrophy of the optic nerve was seen but twice; and
the pupillary reflexes were always present. A characteristic symptom
is nystagmus, which appeared in 06 instances, and would have doubtless
been seen later in many others. It is less common than the affection of
speech, and develops with or later than it. There are only 6 cases
reported in which nystagmus was present, without mention of difficulty
of articulation. The form is almost always " ataxic nystagmus," as
named by Friedreich ; i. e., appearing only when the eyes are fixed
upon an object. " Static " or ordinary nystagmus is mentioned in but
3 instances. Vision was impaired in a number of cases in which no
ophthalmoscopic examination was made.

The intellect is reported as possibly weakened in 21 instances, but in
most of these the affection was more than questionable. In only a few
cases does there appear to have been any actual mental involvement,
and the causal relation of the disease to this is very doubtful.

Vertigo is not infrequent (29 cases); sometimes as a very early and
perhaps accidental occurrence. It is often severe, and may persist even
when the patient is in the recumbent position.

ral and secretory disturbances are usually slight, possibly acci-
dental. They are reported in 42 cases in all, to be divided as follows :
Affection of the bladder, 13; affection of the rectum, 4 ; impotence, 3
(possibly 4); disorders of menstruation, 10; palpitation, 13 ; persistent
acceleration of the heart, 8 ; profuse sweating, 3 ; gastric disturbances, 9 ;
dyspnoea, 5 ; precordial anxiety, 2 ; salivation, 5 ; polyuria, cough, inter-
mittent albuminuria, nervous crises, each 1. Some of these disturbances
were among the early symptoms.

Pathological Anatomy. — The 12 patients on whom autopsies have
been made were those of Friedreich, 5 cases ; Kahler and Pick, Brousse,

386 GRIFFITH, FRIEDREICH'S ATAXIA.

Smith, Erlicki and Rybalkin, Gowers and Pitt, each 1 case ; Riitimeyer,
2 cases. There has been found no change in the brain (excluding the
medulla) connected with the disease, except that the pons was small in

I instance. The medulla was atrophied in 1 case, and the cord smaller
than normal, throughout or posteriorly, in 11 cases. Spinal meningitis
was present in 10 cases, in 6 of which it was limited to the posterior
portion of the cord. There was thickening of the ependyma of the fourth
ventricle in 2 instances. On microscopical examination, there was found
slight extension of the posterior sclerosis to the medulla in 5 or more
cases. The cord exhibited sclerosis of the posterior columns in all 12
patients ; sometimes nearly uniform throughout, sometimes more com-
plete above than below. In 6 instances, there was a small portion of
healthy white matter next to the commissure or to the corriua. The
lateral pyramidal tracts were very uniformly sclerosed in 11 cases; the
remaining one being the first case of Friedreich's, in which the more
imperfect methods of microscopical examination then in use may have
failed to reveal slight changes. It is important to observe that in 7 of the

II there was a narrow strip of healthy tissue between the diseased portion
and the posterior horn. The direct cerebellar tracts appear to have been
involved in 7 cases. A peripheral zone of degeneration passing forward
from this tract was seen in parts of the cord in 5 instances. The ante-
rior pyramidal tracts were sclerosed on one or both sides to some extent
in 6 cases. The columns of Clarke were degenerated in 8, and probably
in 9 instances. In a few cases degeneration of various other parts
of the gray matter has been reported. Inflammation in and around
the central spinal canal occurred in 4 instances ; and supplementary
canals were seen in 3. The posterior nerve-roots were more or less
diseased in all the cases ; and some of the strands of the anterior roots
in 1 instauce. Slight alterations in some of the peripheral nerves are
twice reported. The histological changes in the cord consist in an over-
growth of neuroglia at the expense of the nerve-fibres. A finely fibril-
lated or granular substance develops, and corpora amylacea are fre-
quently very numerous. In 1 instance — a case of Friedreich's— tin-
lateral tracts underwent a simple softening, instead of sclerosis.

Pathology. — Friedreich's ataxia has been variously considered Bfl >
form of tabes, a combination of this with disseminated sclerosis, a cere-
bellar disease and an independent affection. There seems to be DO
reason now to deem it other than a distinct disease, intermediate elini-
eally between tabes and disseminated sclerosis, or, as placed more exactly
by Gowen, between the former and ataxic paraplegia. The opinion of
Friedreich and of some others is that the primary lesion is a meningitis,
or a sclerosis of the posterior columns spreading by a meningitis.
Bohulta ooraridered it a diffuse inflammation of the whole posterior half
of the cord. There are, however, better reasons for believing it to be a

GRIFFITH, FRIEDREICH'S ATAXIA. 387

oombined systemic spinal disease, at the least for certain parts of the
conl. The early age at which it develops and the smallness of the cord
in so many cases render it probable that there occurs, under an heredi-
tary predisposition, an arrest of development of certain nervous systems
during foetal life. This probably takes place, as Kahler and Pick say,
at the time of the sheath-formation, since the tracts most sclerosed are
the ones last to acquire medullary sheaths, according to the statement
of Pitt. Later in life, degeneration of these imperfectly formed fibres
occurs.

This view almost necessitates the belief in a systemic degeneration,
which is further strengthened by the existence, in so many cases, of the
band of healthy tissue between the diseased lateral tract and the pos-
terior horn, as well as by the frequent absence of meningitis, either entire,
or from all parts except over the posterior columns. It is clear that
in such cases there could have been no spread of the disease from the
posterior columns, either by contiguity or by a meningitis.

Diagnosis. — The principal diagnostic symptoms of Friedreich's ataxia
are : Evidences of hereditary influences, the occurrence of several cases
in a family, early age of development, motor ataxia, static ataxia, affec-
tion of speech, nystagmus, talipes, curvature of the spine, some degree
of paralysis; further, the absence of knee-jerk, of marked sensory,
trophic, vaso-motor and visceral affections, of atrophy of the optic nerve
and of affection of intellect. But, as in all diseases, the diagnosis must
be based on the aggregation of symptoms rather than on individual ones.
The affection is especially to be distinguished from tabes, disseminated
sclerosis and ataxic paraplegia. Tabes is recognized by its development
in adult life and singly, by the occurrence of severe lancinating pain, of
optic nerve atrophy, of alteration of the pupillary reflexes, and often of
marked trophic and visceral affections ; and by the absence of affection
of speech and of nystagmus. The gait, too, often differs, as already
described. Disseminated sclerosis is very exceptionally hereditary,
usually develops at a more advanced age, and further differs in the
presence of remissions, static nystagmus, rhythmic oscillations, ankle
clonus, exaggerated knee-jerk, intention tremor and disturbance of intel-
lect ; and in the absence of Romberg's symptom. Ataxic paraplegia is
distinguished by its occurrence in adult life and not in several members
of a family ; and by fche presence of increased patellar reflex, and the
absence of nystagmus, and of marked affection of speech. The symptoms
of Friedreich's ataxia resemble those of cerebellar tumor only in a single
particular ; viz., the oscillating gait ; and the disease can scarcely be
confounded with hereditary chorea, since the latter has a distinctly
different history and mode of termination, and exhibits no truly ataxic
symptoms or diminution of the patellar reflex.

388 GRIFFITH, FRIEDREICH'S ATAXIA.

Duration, Prognosis and Treatment. — The course of the disease
is steadily onward toward a fatal termination, and only in rare cases
has there been a temporary arrest. Its duration may be only a few years,
but is usually very extended, unless cut short by some intercurrent
malady. One patient of Vizioli's, in whom the affection began in infancy,
died at the age of 46 years. As far as I have been able to discover, 25
cases are reported to have died, but in only 1 was death evidently the
result of advancing weakness; though in 5 the cause is not clearly stated.
It follows, therefore, that the prognosis is most unfavorable as regards
recovery ; and as concerns the duration of life, must be determined for
each individual case.

Treatment has been, unfortunately, of little avail, though silver,
arsenic, phosphorus, zinc, etc., have been and may be tried. Every
means should be used to maintain and increase the general strength by
tonic treatment ; such as cod-liver oil, change of air, sea bathing, elec-
tricity and massage. A plaster jacket was a great relief to one of my
patients who had become unable to sit upright on account of the spinal
curvature ; and one of Smith's cases improved greatly under this treat-
ment, combined with electricitv.

REVIEWS.

Treatise ok Dislocations. By Lewis A. Stimson, B.A., M.D., Pro-
fessor of Clinical Surgery in the University of the City of New York, Sur-
geon to the New York, Presbyterian and Bellevue Hospitals, etc. With
one hundred and sixty-three illustrations. 8vo. pp. 539. Philadelphia:
Lea Brothers & Co., 1888.

Tins work, by Dr. Stimson, is the companion piece to his well-known
treatise upon rVocfttret; but, unlike most such works, is an entirely
separate volume. It is the most complete disquisition upon the subject
in the English language, and probably in any language ; not because
tlu- author is better qualified for his work than Malgaigne, Cooper or
Hamilton, but on account of the vastly increased facilities for collecting
illustrative material in the Index Medicos, the Index Catalogue of the
Surgeon- General s Office and the mass of publications which are thus
made accessible for this purpose. By means of these resources he has
been enabled to present complete descriptions of several rare forms of
luxation, which previously had never been adequately observed and
studied, and to correct various errors which, having crept into popular
text-books, have been widely diffused.

The first 116 pages of the book are devoted to the general considera-
tion of dislocations, including statistical tables in regard to the frequency
of luxations of the different articulations, the pathological changes in
recent and old dislocations, the complications which may arise and the
broad principles of treatment. This part of the work seeks to lay a
firm scientific foundation upon which the more practical portion of the
treatise may securely rest.

An instructive chapter upon non-traumatic dislocations, especially
those of congenital character, forms Part II. of the work. Congenital
dislocations are believed by the author to depend upon an arrest of de-
velopment of the bones forming the articulation, rather than upon any
injury to the child during labor or during fa?tal life. These congenital
dislocations are found usually at the hip, and are frequently double, but
the shoulder, elbow and knee are also liable to this malformation, though
but rarely.

Part III. deals with special dislocations, and forms the bulk of the
work, 417 pages being devoted to this subject. In the preparation of
this section, we see evidence of the most thorough investigation and
research. The literature of the whole world has been brought into
requisition, and the result is a comprehensive and systematic description,
not only of the usual forms of dislocations, but of the rare and anomalous
forms which are recorded here and there in various publications aa
curiosities.

Beginning with dislocations of the jaw, the author describes two-

390 REVIEWS.

unusual injuries which can also be classed as fractures, dislocation
backward, in which the condyle of the jaw is driven against the anterior
wall of the external auditory canal, with the effect of fracturing the wall
of the canal, and of fixing the condyle in an abnormal position ; the other
is dislocation upward, in which the condyle has been forced through
the glenoid fossa into the cavity of the cranium, and is a genuine frac-
ture of the base of the skull, and an exceedingly fatal one, too.

Dislocations of the sternum are the subject of a complete chapter, as
are also those of the ribs. Considerable space is devoted to the consider-
ation of dislocations of the clavicle, and it is satisfactory to note that
the dislocations of the acromial end of the clavicle are spoken of as dis-
location of the clavicle, instead of dislocation of the scapula, which would
be the ordinary nomenclature. All these luxations are acknowledged
to be easy to reduce, but very hard to retain in position.

Owing to the anatomical configuration of the shoulder-joint, and to
its exposed situation, luxation of this joint is of great frequency, forming
about fifty per cent, of all cases ; hence the consideration of these dislo-
cations is of the greatest importance. Dr. Stimson adopts a classifica-
tion which differs slightly from that which is in common use. Using
the direction in which the primary displacement of the head of the
humerus occurs as a guide, he adopts the following schedule:

{Subcoracoid ; very common.
Intracoracoid; exceptional.
Subclavicular.

{Subglenoid; uncommon.
Erecta; very rare.
Subtricipital.

Posterior. {Subacromial; rare.

( Subspinous; very rare.

Upward. Supraglenoid ; very rare.

This classification differs first in the substitution of the term " intra-
coracoid " for "subclavicular," and all dislocations in which the head of
the humerus lies to the inner side of the coracoid process are placed in
this subdivision. It is somewhat startling to be told that subglenoid dis-
location is uncommon, when most English and American authors declare
it to be the most frequent of all the humeral dislocations. A sub-variety,
luxatio erecta, is added to this group of subglenoid dislocations. Only
seven cases of this injury have been described ; one of which was ob-
served by Dr. Alberti, of the Charite, in Berlin; and the reviewer well
remembers hearing the case discussed in the wards of the Charite a
short time after its occurrence. The subtricipital dislocation is another
anomalous variety, only one case having been described. The upward
dislocation, or supraglenoid, has been seen in but a few cases. The
existence of this dislocation has been denied, but the cases of Holmes
and Alberti, upon which autopsies were held, have proved that it is a
v. i itable supraglenoid luxation. At a final examination, some years
ago, the professor of surgery asked a student from Georgia to mention
the dislocations of the shoulder, and ho mentioned the upward di>loca-
tion amongst the rest. The professor thanked him, and asked him to
report the first case of upward dislocation which he might meet. It
seems now that we will have to include this as one of the possible luxa-

STIMSON, TREATISE ON DISLOCATIONS. 391

tfons of the humerus, and certainly not give our students bad marks for
mentioning it as such.

W are surprised that the test of Dr. Dugas, for all dislocations of the
shoulder, is cot thought of sufficient value to merit adequate description
or a mention of the originator's name. It seems to us to be an almost
infallible diagnostic sign. Hamilton's test is also ignored. It is as fol-
lowfl : When there is a dislocation a ruler can touch the acromion pro-
cess and the external condyle of the humerus at the same time; if the
bones are in their normal position, this cannot be doue. These tests may
not be needed by the skilled surgeon, but are very serviceable to the less
dextrous general practitioner.

Quite a formidable array of traction apparatus is portrayed, but most
_<ons in these days of improved methods would not dare to use them.
Wt certainly would prefer operative interference under antiseptic pre-
cautions rather than a trial of such barbarous appliances, and Dr. Stimson
holds to the same opinion. It is a satisfaction to find Kocher's method
of reducing subcoracoid dislocations fully described, as it is certainly
the easiest and best for most acute cases, and comparatively few prac-
titioners are acquainted with it.

ing over dislocations of the elbow and wrist, which are thoroughly
treated in the text, let us pause to learn the author's opinion as to the
difficulty of reduction of luxations of the metacarpophalangeal articu-
lation oi' the thumb. As is well known, dislocations backward of the
thumb are sometimes very difficult to reduce, and this difficulty has
been ascribed to various causes by different authors. Dr. Stimson favors
the view that the difficulty in reduction is due to the interposition of
the anterior ligament with the sesamoid bones, and that forced dorsal
nVxion should be employed, in order to slide the ligament well over the
head of the metacarpal bone. The tension of the short flexors also aids
in preventing reduction. Forward dislocation of the thumb occurs occa-
sionally, but does not usually present the same obstacles to reduction.

Dislocations of the hip occupy a large space in the work, and justly
so. One is struck with the great value of the contributions of American
surgeons to the elucidation of the pathology and treatment of this very
severe accident. Dr. Stimson's classification differs again from that in
ordinary use with English-speaking physicians, and whilst, undoubtedly
correct, it seems to us that the usual classification is a good one for
working purposes, if we bear in mind that in a few rare cases the head
of the femur is found in anomalous positions. Amongst the dorsal dis-
locations are placed the anterior oblique and the everted dorsal, ex-
amples of which are but rarely met with, and are not described in most
text-booka The treatment of dislocations of the hip has go radically
changed, that the old methods of traction are scarcely mentioned. The
recent procedures of manipulation were undoubtedly first introduced by
Nathan Smith, of New Haven, but the perfection of the method and the
correct interpretation of the principles upon which it depends, are due to
the genius of Henry J. Bigelow, of Boston, and his name will always
be honorably nmorintrd with this method of treatment.

We are admonished that this review has already reached sufficiently
large proportions. It only remains for us t<> say that the treatise is
published by Lea Brothers A: Co., of Philadelphia, and that the typo-
graphical work is good and the illustrations well executed and, with a

VOL. 96, KO. 4.— OCTOBER, 1888. 28

392 REVIEWS.

few exceptions, demonstrative. Dr. Stimson has produced a most valu-
able book, and one which will be regarded as authoritative for a long
time to come. R- ^ •

An Illustrated Encyclopaedic Medical Dictionary. Being a
Dictionary of the Technical Terms used by Writers of Medicine
and the Collateral Sciences ; in the Latin, English, French and
German Languages. By Frank P. Foster, M.D., Editor of the New
York Medical Journal, with Collaborators. Volume I. New York : D.

. Appleton & Co., 1888.

An important place certainly exists for a work having the purpose of
this dictionary. As Dr. Foster remarks in his preface, a comprehensive
dictionary giving adequate attention to English, French and German
terms in the same vocabulary has not hitherto been produced. Such a
want was partially recognized by Littre' and Robin, in appending brief
Greek, Latin, German, English, Italian and Spanish vocabularies to
their revised edition of Nysten's Dictionnaire de Medecine. It was
more nearly met in Palmer's Pentaglot Dictionary. But a lexicon in
which the student of medical science and literature in the three modern
languages which contain their largest portion, could find all technical
words with English definitions, has not before existed. There is great
interest, therefore, attaching to this atttempt of Dr. Foster and his
eleven collaborators to accomplish so serious and useful a task.

Anyone's first observation in examining the present volume must be,
that its size, being the first of four volumes, is immense. It is a quarto,
with small print, 752 pages. The whole work, therefore, may be ex-
pected to consist of about 3000 pages. Webster's Unabridged Dic-
tionary, of all words in the English language, has less than 2000 pages;
Harper's Latin Dictionary (1879), with a slightly smaller page but
smaller type, has 2019 pages; Liddell and Scott's Greek Lexicon (1883),
with a page a little larger and similar type, has 1776 pages. Yet these
works include all the words of the languages respectively attended to ;
while this deals only with those belonging to medicine and the sciences
collateral to it.

When we come to ascertain how this great magnitude is accounted
for, we find that it is not by all, or nearly all, the subjects mentioned
being treated extensively as in a cyclopaedia. Less than 140 articles
occupy more than half a page. Most of the terms are defined briefly,
with, generally, their equivalents in Latin, French and German; some-
times in Italian and Spanish. But a number of articles an excessively
long. Acid, the English word, has a page and a half. But oeide,
French, has more than fifteen pages; consisting of a catalog n> of French
names for acids, with their English equivalents; some cross- referen
also being given. For much of this occupation of space, we can see DO
good reason. Take a few lines at random: UA. amido-hippurique;
amiilo -hippurie acid. [B.] A. amidn-hydrocinnamique ; amidohydro-
omnamio lamidophmylpropionic) acid. [B. 38] A. amido-is&hiorique.
A mi. lix'thionic acid; taurine. [R] A. amido-isooaproique. Amido-
isocaproic acid; isoleucene. [B.] A. amido-iaophtalique. Araido-

FOSTER, MEDICAL DICTIONARY. 393

isophthalic acid. [B.] See amidophthalic acid." Except where a
different name is also used (as taurine, isoleucene, etc.) for the same sub-
stance, ninety-nine iu a hundred of these renderings from French into
English are so obvious as to be quite superfluous. A few words of ex-
planation of the French terminations, under the heading acide, would
suffice for any student. Similar redundancy occurs with the Latin
term mddum, which has a catalogue filling nearly five pages. Yet each
of these acids will have, under its English name, at least a brief article
If. Acetic <ti-iil, for instance, has thirty lines; acetum, nearly a
Under >ria, arterie and artery there are nearly thirty

E Those under the French, Latin and German heading are alpha-

etical lists or catalogues of all the arteries of the human body, rendering
the foreign into English names. Under the English headings, artery, we
have these all again alphabetically enumerated, with a brief description
and twenty five good illustrations, after Henle. Pausing here, we ask,
For whose benefit is this manner of presentation of the arterial system?
Will the medical student use it for his study of anatomy ? Probably
both he and the "busy practitioner" will make shorter, and yet more
satisfactory, work of it, with Gray, or Allen, or some other anatomical
treatise.

Another question of proportion occurs on turning to articles like those
on alh/l, a page and a half; aloe, aloes and aloes, four pages; aluminium,
nearly two pages; ammonium, nearly eight pages; amyl, more than two
pages; cw&wotne, antimomwn and antimony, between five and six ;
but, most remarkable of all, anemone, about one page; aristolochia, more
than two pages; artemina, the same; and astragalus, almost entirely
treating of the botanical genus, nearly two pages. Yet we find angina
pectoris disposed of in less than a column, and auscultation in less than a
quarter of a page. Under asthma, the descriptive part fills twenty lines;
the remainder, a page, contains a catalogue of terms indicating the
varieties of asthmatic affections, as they are named in different lan-
guages. No word is said, moreover, in this article, concerning the treat-
ment of asthma. Surveying, then, the enormous accumulation of chem-
ical, botanical and linguistic learning brought together in some of these
articles, we cannot resist the temptation to paraphrase the famous saying
about a scene upon the battlefield: " (Test nxagnifique, mais ce n'est pas
la mi

Several articles, on important subjects, have a good measure of cyclo-
paedic fulness, with ample illustrations; as those on amputation, appara-
tus, bacillus, bacterium, bandage, bone and a few others. Yet the work is
far from possessing the symmetrical completeness of a cyclopaedia. It is,
with some exceptional enlargements, a trilingual dictionary. As such, it
has great value. But we cannot withhold the opinion that all the really
important advantages of such a dictionary might have been obtained with-
out passing much beyond the limits usual to such a work. With one-
fourth of its present bulk, it would have been more convenient for use,
and, because of its lower cost, it would have been available for a much
larger circle of readers. As, however, there are many who need a work
to meet its main purpose, we may hoj>e that the stupendous labors of its
preparation may not be without sufficient reward.

A few words may be said concerning Dr. Foster's system of orthog-
raphy for medical words. In his preface he asserts a general regard for
etymology in choosing between two ways of spelling the same word.

394 REVIEWS.

Thus, he prefers thyreoid to thyroid, aneurysm to aneurism, and rhachitis
to rachitis. In these days of phonetic spelling reform, Volapuk and
World-English, brevity and simplicity are steadily gaining in the contest
with etymological prepossession in orthography. We believe that lexi-
cographers will do well to respect this tendency ; not only because it is
manifest in popular usage, but because it has in its favor the highest
literary authority, and belongs to an inevitable movement of cosmopolitan
progress. H. H.

Ptomaines and Leucomaines, or the Putrefactive and Physiological
A i.kaloids. By Victor C. Vaughan, Ph.D., M.D., Professor of Hygiene
and Physiological Chemistry in the University of Michigan, and Director
of the Hygienic Laboratory; and Frederick G. Novy, M.S., Instructor
in Hygiene and Physiological Chemistry in the University of Michigan.
12mo. pp. 316. Philadelphia: Lea Brothers & Co., 1888.

This excellent work really fills a long-felt want and will be warmly
welcomed by the scientific world, for in a short space it tells of the accu-
mulated knowledge concerning the mysterious productions in organic
matter. Scattered through chemical and physiological literature are
accounts of the ptomaines and leucomaines, but this work is the first
attempt to collect all the facts of value relating to them. Sir William
Aiken, 1887, delivered a lecture at the Army Medical School at Xetley
on the Animal Alkaloids, which was subsequently published in a book
of sixty pages; and Dr. A. M. Brown edited a translation of a work by
MM. Gautier and Peter on the Ptomaines, Leucomaines and Microbes.
These treatises, however, only review the subject in a partial way and
but portions of the large field were gone over. The book now under
review is the first comprehensive treatise, and carries the reader through
the literature of the subject, and furnishes an exhaustive history of the
chemist rv and pathological bearings of the microorganisms and their
results.

The importance of the subject may be appreciated when we learn that
the study of bacteriology, now so interesting and valuable to the scien-
tific world, is not complete without a knowledge of the results produced
by the minute organisms, for, as has been stated by Vaughan, the small
bodies seen under the microscope may be either the cause or effect of a
disease, while the ptomaines produced by these organisms may he the
factors responsible for a condition necessary to the life of one of the
lesser organisms, while, on the other hand, the organisms may be produ
of the ptomaine.

The hook convinces us that no person can grasp the full importance
of the study of bacteriology without a knowledge of the chemistry of the
ptomaines. If, for instance, we take the case of poisonous fish or meat :
or find under the microscope certain bacteria, and if our investigation

he < tinned do farther, we may ascribe the poisonous effect to ti

hodir>. I'.ut if the subject is followed more in detail we shall ascertain
that a real poison, capable of being isolated and demonstrated by means
of reagents, is present, and that the bacteria are either products of this
o or really subsist on it.

GAIRDNER, LECTURES TO PRACTITIONERS. 395

Without going more into detail, we would recommend the perusal of
this important work. The authors have divided the topic into conve-
nient branches, siirh as the ptomaines found in poisonous food, those
that are the cause of effect of disease and those of interest to the toxi-
cologist, as giving reactions identical with some of the vegetable poisons.
lie close of the book the authors give a complete and exhaustive
bibliography of the subject, which will be a valuable aid to students and
other- in\ > Btigating special branches of the study.

W • congratulate the writers on their successful contribution to scien-
tific literature, and would cordially commend the work as a readable and
valuable treatise on an interesting topic. W. K. N.

Lbctukbb to Practitioxers. I. On* the Diseases Classified by the

Registrar-General as Tabes Mesenterica. By W. T. Gairdner,

M.D., LL.D. II. Ok the Pathology of Phthisis Pulmoxalis. By

PH Coats, M.D. 8vo. pp. 285. With twenty-eight engravings on

wood. London : Longmans, Green & Co., 1888.

The lectures contained in this volume were delivered in the Western
Infirmary, Glasgow, during the month of October, 1886. Owing to
various circumstances, chiefly connected with the professional engage-
ments of the authors, there was a delay of over a year in publishing
them. This delay, the authors explain, has been of no detriment to the
book, as it has permitted a fuller revision than would have otherwise
been possible. In this view we fully concur, seeing that the interest
and real value of the lectures lies not so much in the facts presented as
in the way in which they are presented, and in the strong impress of
the individuality of the author which each set of lectures bears. What-
ever changes of view in regard to tuberculosis may occur in the course of
the next ten years, whatever fact-obscuring fogs of traditional opinions
may, by that time, have been swept away, these lectures will still be
read with interest by students of pathology, if not for the truth of what
is written, for the way in which it is said.

the facts are all-important. If there is any way to a rational
treatment of tuberculous diseases, to a certain prophylaxis against their
spread, it lies through their pathology — a country well cleared of late
but still abounding in obscure by-ways and misleading landmarks. The
civilized world, medical and lav, is rather apathetic about consumption.
It has gotten rid of the plague, and nearly rid of typhus epidemics;
leprosy has been driven out of England, and smallpox has been made
manageable, but one death in seven from all causes is still due to tuber-
culosis pulmonum, and some part of the remainder is due to other tuber-
culous diseases. If we feared these diseases as they merit, as we do the
cholera or yellow fever, we would in time suffer less from their ravages.
But we have strangely grown used to them and view them with a sort
of fatalistic indifference, broken now and then by a ripple of inte
awakened by the discovery of some new fetish, a wash bottle, or an air-
tight box, or some other ingenious device, the impotent offspring of
mechanical skill and ignorance of pathology.

396 REVIEWS.

Dr. Gairdner's lectures constitute a strong plea for the closer clinical
study of the group of diseases designated in England by the term tabes
mesenterica, and in France by the word carrean. The argument is in-
genious, logical, telling; it is forcible in style, rich in matter, abundant
in illustration ; pleasant reading and wholesome teaching. Thus, page 37,

" I am not, therefore, in any way pretending to teach you anything new,
when I say that the diagnosis of tabes mesenterica, or carrean, is inextricably
mixed up with the signs of peritoneal rather than those of mesenteric gland-
ular disease; and that it is even doubtful how far the latter enters at all into
the diagnosis from physical signs as commonly observed. But I am, never-
theless, clearly of opinion that the precise observation and the just signifi-
cance of those physical signs in cases which are not fatal, but which make, at
all events, a temporary, and in some cases a permanent recovery, has not
hitherto had sufficient attention bestowed on it, and the consequence of this
has been that .... the prognosis in these diseases inclines far too
much to the grave and even hopeless aspect of them, and fails to recognize
the existence of more or less similar cases which would tend to qualify that
prognosis."

Dr. Gairdner holds also that the general prognosis in tuberculous and
chronic peritonitis is more gloomy than the facts warrant.

We cannot commend too highly these terse, well worked out, prac-
tical studies in the pathology of pulmonary phthisis by Dr. Coats.
They deserve the attention of the widest audiences of the medical pro-
fession, as a clear presentation of the more important facts upon which
the doctrine of the infectious nature of pulmonary consumption rests.
They are wholly interesting and instructive and, in parts, novel. Space
forbids our reviewing them in extenso, a fact which will accrue to the
gain of those who may be thus influenced to the task at once more pleas-
ant and more profitable of reading them for themselves. J. C. W.

Medical Lectures and Essays. By George Johnson, M.D., F.R.C.P.,
F.R.S. London : J. & A. Churchill, 1887.

" I profess both to learn and to teach anatomy," wrote Harvey, in the
dedication of the treatise De Motu Cordis et Sanyuitiis, "not from books
but from dissections; not from the positions of philosophers but from
the fabric of nature." The learned author of A Defence of Ham
1 larveian Oration of 1882, and the concluding essay of the volume before
tit, might well have made the same profession in regard to clinical medi-
cine— both to learn and to teach, not from books but from patients, not
from t lie positions of philosophers, but from the facts of disease. Every-
where, the patient is the text ; on every page, the symptoms and signs, as
determined by morbid changes ID function and structure, the relation

of pathological to normal anatomy, of pathology itself to phytioloffy

form the body of the discourse. Speculation is rare and held within the
lines of the facts as the author has seen them; and he sees, for the most
part, with char vision. Not always as other men have seen ; sometimes
quite differently. The controversies are well known. The leu

WILLIAMS, CANCER AND TUMOR FORMATION. 397

to-day rive not only larger amplification, but far better definition than
those of a quarter of a century ago. But Dr. Johnson has seen, for the
must part, we repeat, with singular clearness and accuracy. He is at
once the pathologist and the clinician, but, above all, the practitioner.
1 1. rein lies the value of his writings ; they are practical. His pathology
H no mere curious research, nor with him is diagnosis only the exercise
of much learning and great skill to solve obscure problems, nor thera-
peutics vain, or at most, an empirical art. He is not of that school. He
is robust, earnest, hearty, believing. Not too much concerned with
refinements, but vastly anxious to know what is really the matter, how
it came about, and how to cure it. A very good kind of a doctor, of a
type that will survive the overgrowth of specialism.

These lectures and essays are mostly reprints of papers that have
appeared in various forms at different times during the last thirty years.
Some portions are recently written ; the rest have been carefully revised.
They represent the author's latest and most matured opinions upon the
subjects of which they treat, and especially upon such vexed questions
as the pathology and treatment of cholera and of the various forms of
Hright's disease of the kidneys, the relation of membranous croup to
diphtheria, and the proximate cause of epileptiform convulsions. The
topics are of the most varied kind, their presentation direct and simple,
the style matter-of-fact, yet terse and dignified. The illustrative cases
are numerous and valuable. Those whose " past is secure " will read
these essays with interest ; those whose professional life lies before them,
with profit ; we who stand midway will find in them both entertainment
and instruction. J. C. W.

Thk Principles of Cancer and Tumor Formation. By W. Roger
Williams, F.R.C.S., Surgical Registrar to the Middlesex Hospital, Sur-
geon to the Western General Dispensary. London : John Bale & Sons,
1888.

Tins work is intended as an introduction to a contemplated treatise
on the pathology and treatment of cancer and tumor formation, in six
part-, and including the general and special pathology and treatment of
the diseases named.

There are always difficulties in judging the whole from a part, and
these seem unusually numerous in the present case. At the very outset
we are compelled to stop and try to discover the meaning of the title.
Believing, as we do, that the word " tumor " conveys only a negative
idea, we hold that cancers furnish the very pattern and model of a
" tumor.'' What our author understands, then, by " cancer and tumor"
we fail to gather from this volume. Perhaps in the promised five we
shall learn more. A large part of the work is taken up with some
curious facts about vegetable neoplasms. The chapters on the develop-
ment and etiology of animal neoplasms contain no definite advance in
those lines.

Whatever may be the similarity between the formation of galls and
that of tumors in general, cancer will probably be found to depart most
widely from that mode. The adoption of His's histogenetic scheme,

398 REVIEWS.

which the author has advocated elsewhere, has much in its favor. We
await, with considerable interest, the continuation of Mr. Williams's
treatise. Cr. D.

The Transportation of the Disabled, with Special Reference to
Conveyance by Human Bearers. By James E. Pilcher, Assistant
Surgeon, U. S. Army. 8vo. pp. 23. New York, 1888.

The Ambulance Corps of the War of the Rebellion was eliminated
in the reorganization of the Federal Army, but recently, after prolonged
study of the needs of the service, the Medical Department of the army
has formed a hospital corps which will number a thousand men, re-
cruited by four " company bearers " from each battery, troop or com-
pany, who shall be especially instructed in carrying and giving first aid
to the injured.

Finding the manuals on the subject deficient regarding the use of
litters and also extemporized methods of carrying patients immediately
after injury, Dr. Pilcher described, in a lecture before the Military
Service Institution, in March last, methods which he had devised, and
which he demonstrated by trained bearers. This lecture, in pamphlet
form, with illustrations, forms a manual of the subject, clear, practical
and ingenious, and the Department is to be congratulated upon having
such an excellent brochure available for the instruction of the corps.

BEITRAGE ZUR ANATOMIE DE3 SCHWANGEREN UND KREISSENDEN TjTEIU s.

By Hor.MEiER and Benckiser. Stuttgart: Ferdinand Enke, 1887.
Contributions to the Study of the Anatomy of the Pregnant and
Parti iuknt Uterus.

This is a series of sixteen facsimile illustrations of sections made
through various uteri, with explanatory text. The illustrations are
highly satisfactory, and the text concise and clear.

The conclusion is reached (and, we think, demonstrated) that the
uterus in all phases of its physiological and pathological activity con-
sists of three portions : upper and lower segment, and cervix. The low ei
segment is that part of the uterine body which is between the interna]
us and the attachment of the peritoneum; this portion is very small in
the non-pregnant uterus, but during pregnancy, labor, and the puerperal
gate |, , es distinct anatomical and physiological characteristics; it

H clearly distinguished from the cervix. T^he cervix remains unchanged

until the end of pregnancy and continues to possess its characteristic
mueoua membrane, while the lower segment of the uterus is lined by
decidua.

This work furnishes an illustration and amplification of the views of
Professor Behrdder, and originated in work done by him with ti
ance of Hofmeier. E. P. D.

PROGRESS

.MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

FRANCIS H. WILLIAMS, M.D.,

ASSISTANT FROrtMOR or MATERIA MEDICA AND THERAPEUTICS IN HARVARD UNIVERSITY.

The Relation of Drugs to the Secretion of Bile.

As is well known, there is no therapeutic question in regard to which so
much doubt and disagreement prevail as that relating to the action of drugs
on the biliary secretion, or, as is commonly said, on the liver. Observers
have so contradicted each other that one hardly knows where to look for
truth. Perhaps the experiments of Rutherford have been most generally
accepted. Recently Prevost and Binet have published the results of most
exhaustive inquiries into the subject, controlling and testing the results of all
previous experimentation, particularly that of Rutherford. The experiments
are given in exact detail, of much interest from a physiological point of view,
and those interested may refer to the original articles [Rev. mid. de la <S
Rom., May, June and July, 1888). The method employed was to establish
a permanent fistula from the gall-bladder, the track of which was opened from
time to time for the experiments. The authors lay stress upon this, as they
claim for the method advantages over the canula in the estimation both of
tin- normal flow and that under medication. In confirmation of the statement
of Rohmann, the infliction of the biliary fistula has been consistent with the
preservation of good health in the animals, if only fat is withdrawn from the
diet,

Bil'' itself, Prevost and Binet find to be the most powerful cholagogue,
whether given in the natural state or in the form of a dry extract. If this be
true, and it is only confirmatory of what many other observers have asserted,
a good deal of doubt is thrown upon the conclusions of Rutherford, since he,
believing the ingestion of bile to have no influence over the secretion of .bile,
actually used it as a vehicle for many of the drugs with which he was experi-
menting. Bile is also toxic in sufficient doses, subcutaneously, and will
produce death, with symptoms of collapse. The intestine higher up is found,

400 PROGRESS OF MEDICAL SCIENCE.

post-mortem, full of bile; lower down, full of a diarrhceic matter, often
bloody; sometimes the urine is bloody.

The following substances [Group I.] these observers have found to increase
the flow of bile, viz., urea (in a single instance, c accompanying severe gastro-
intestinal trouble) ; oil of turpentine and terpine (on the supposed action of
ol. terebinthin. on the biliary secretion is based the treatment of biliary
litliiasis after the method of Durande. The present observers find that
turpentine and its derivatives produce a " notable" increase in the secretion).
Chlorate of potassium, which also has long possessed reputation as a chola-
gogue, increased the flow by once or twice the normal. Further, benzoate
and salicylate of sodium (two or three times the normal), salol, euonymin
and muscarin (subcut.).

Group II. Substances producing only a slight or doubtful and inconstant
increase are, alkaline salts; carlsbad salts, propylamine, antipyrine, aloes,
cathartic acid and rhubarb ; hydrastis canadensis, ipecac, and boldo. Thus
cathartics and the alkaline salts, which Rutherford considered cholagogue in
non-cathartic doses, these observers found lacking in any such power.

Group III. Substances diminishing the secretion — iodide of potassium,
calomel, iron and copper, atropine and strychnine. In regard to calomel, the
writers have not been able to confirm Rutherford, who believed that what
cholagogic action calomel had was owing to the transformation into corrosive
sublimate. The last-named substance given by itself produced no increase.

Then follows another group of substances which are without action. In
regard to the elimination of drugs through the bile, the conclusions of the
observers are that it is unimportant, the quantities being so small. It is in-
teresting to note that they found ox bile present in the bile of a dog which
had taken it. There is no constancy between the elimination of a substance
in the bile and the effect of the same on the activity of secretion. The sub-
ject appears to have been particularly well studied and the paper and its
conclusions deserve attention.

The Sterilization of Catgut.

Prof. Reverdin, in Geneva, publishes in Rev. mid. de la Suisse Rom.,
June, July and August, 1888, some conclusions he has made from a clinical
and experimental study of catgut. His dissatisfaction with the quality usu-
ally furnished by the manufacturers led him to try sterilization by heat, and
he found that crude catgut (which has not been treated by any fat to preserve
it!) exposed for four hours to a dry heat gradually increased to a temperature
of 284° F. (140° C.)., then placed for a day in oil of juniper and kept in abso-
lute alcohol, ia quite aseptic. His clinical experiences with this catgut cover
eighteen months and it has never failed him ; while numbers of bacteriological
tests have never shown any form of bacterium, though crude catgut and catgut
exposed to oil of juniper and alcohol alone gave colonies, the first always, the
latter often, showing that the dry heat is the essential factor.

The I'i.i -in i Status of the Iodoform Question.

The many papers on iodoform that have appeared the past year have been
brought together by Freyer in Ther. M.mafthefte, June and July, 1888 (see also

THERAPEUTICS. 401

von Kahlden in Centralblatt f Bakteriolog ., 1887, pp. 165 and 194, for a similar
-nig, one of the Danish investigators who first condemned iodo-
form, has the latest word on the subject in Fnrteehritte der med., August 1,
1888, and I Arch., B. 110, H. 2 and 3) is also one of the last to

contribute to the discussion.

It woul<l -f. in, from the great degree of unanimity among the observers,
most of whom, it must be remembered, took up the subject with a prejudice
in favor of iodoform, that it may be considered an established fact that iodo-
form is not an antiseptic — i. <?., is not a parasiticide, not a substance capable
of disinfecting wounds and of hindering general infection. Nor does its
everyday dm imply that it is, for it is to be noted that all surgeons conduct
an antiseptic operation and make the wound aseptic before applying iodoform.
Tw y are with justice placed to the credit of iodoform, viz., that of

local anaesthesia and that of diminishing secretion from wounds. This second
action several observers, including de Ruyter and Neisser, have considered
explained by the destructive power of iodoform over the ptomaines generated
by the cocci, and, further, that it avails to do this through the free iodine or
iodine compound which, it seems demonstrated, is liberated in the wound.
De Ruyter showed, in support of this theory, that iodoform rendered cadaverin,
the best known ptomaine, inert. This, however, does not help the position of
iodoform, as Rovsing points out, for even supposing that ptomaines played so
important a rdk in surgical infection, hitherto all attempts to demonstrate
ptomaines in connection with the commonest and most feared bacilli (of sup-
puration, erysipelas, etc), have failed, and in any case it would make of iodo-
form a substance which allowed the disease (i. e., bacilli) to develop, before it
began the attack, and came but late to the rescue from certain consequences,
the institution of which it had been powerless to prevent. What this fact
about ptomaines may explain, however, is the undoubted favorable action of
iodoform in situations where putrefaction with the formation of stinking
ptomaines is unavoidable — >. e., in the rectum, mouth, nose, and in part in
the vagina ; but even here Rovsing finds an illustration of the central fact,
viz., the impotence of iodoform against the bacteria themselves ; he has seen
repeatedly deaths from septicaemia in extirpation of the lower jaw and vaginal
extirpation of the uterus, where iodoform had kept the wounds fresh in appear-
ance and sweet.

BlTUMIXATKD IODOFORM.

This new preparation of iodoform originated with Ehrman, assistant in
the clinic for syphilis, Vienna, who describes it and reports as to its use in the
Ceittralbl. f. gesmfe. T/ier., July, 1888, p. 385. It is a chemical product made
by the impregnation of tar with iodoform ; under the microscope the char-
acteristic crystals of iodoform are no longer seen, but only hyaline plates.
There is no trace of iodoform odor, but the preparation smells slightly, not
unpleasantly, of tar. This may be covered by a very small quantity of styrax.
Large quantities of water bring the iodoform odor out once more, so that in
- of wounds with abundant secretion there may not be entire absence of
odor.

Ehrman has used this new preparation in twenty-two cases, especially of

402 PROGRESS OF MEDICAL SCIENCE.

chancroids and buboes, in each case alternating the iodoform for purposes of
comparison. In general his cases healed remarkably quickly, but on this he
lays no special stress as it may have been accidental, but it is worth mention-
ing that several cases did well under iod. bitum. that refused to heal under
iodoform simp.

Three advantages it seems to have: 1. Absence of disagreeable odor ; 2.
It does not cause eczema and erythema, the occurrence of which often make
it necessary to give up iodoform ; and 3. It does not, as is often the case with
iodoform, cause redundant granulation in the centre of an ulcer, while at the
periphery the edges are undermined and pus is retained.

Sozoiodol.

This substance was introduced by Lassar last year {Therap. Monat*heft>-,
1887, p. 439). It forms a white powder, showing under the microscope flaky
crystals, is made up of iodine (forty-two per cent.), phenol and sulphur, is
easily soluble in water and alcohol and very stable in mixtures. Applied to
a healthy skin it is well borne in powder and ointment, and is soothing to an
inflamed and irritable integument. Lassar used it in five to ten per cent,
powder and paste (c lanolin or c the oxide of zinc — starch vaseline base of
Lassar's paste) and was well pleased with the results in acute and chronic
eczemas, herpes, impetigo, inflamed skin, mycotic diseases and varicose ulcers.

Recently Fritsche has reported on its adaptability for throat and nose
disease. There are in all four combinations of the substance with bases, viz.,
with sodium, potassium, zinc and mercury. The first two, of a bitter soapy
taste and with an odor like lye, may be applied pure to the nasal mucous
membrane, causing only a moderately strong burning and an increased
secretion of mucus. The zinc compound must be reduced to a proportion
one-fifth to one-tenth, and the mercury salt, which is very irritating, of <>ik'-
tenth to one-twentieth. All were used as powders only. In atrophic catarrh,
ozrena and pharyngitis sicca Fritsche had much better results than with other
applications, the secretion being stimulated and the swelling of the mucous
membrane, where present, diminished. Operative wounds in throat and nose
healed much more quickly than usual. In all of his thirteen cases of tuber-
cular ulcerations the ulcers cleaned and showed a tendency to cicatrize, but at
the time of writing none had completely closed over. Fritsche's cases number
altogether eighty-eight. — Therap. Monatzhefte, June, 1888.

Deodorizing of Iodoform.

Iodoform gr

Menthol gr-j-

01. lavand. puriss gttj.

One minim of an alcoholic solution of lavender in water is sufficient to keep
hands and person from smelling, while the atomi/.ation of this solution will
keep a superficial dressing from smelling of iodoform.— L' Union M
1888, No. 21.

THERAPEUTICS. 403

Bphbdub Mydriatic.

nuriate of ephedrin, in ten per cent, solution, dilates the pupil forty
to sixty minutes after instillation of one or two drops. The dilatation con-
tinues five to twenty hours. The accommodation is not paralyzed. From
iuapness, easy preparation and innocuousness the author believes it will
toe homatropine. — >< hmidVs Jahrb., 1888, i. 21.

Hyoscine.

Bi'ddee, in his thesis (quoted in Deutscher med. Wochentchrift, May 17,

1888, p. 407), publishes the following results of trials : On the tremor of paral-

- agitans, and tremor senilis and alcoholicus it works promptly — also

procuring sleep in these cases — the influence on the tremor is not permanent

however. A constant effect is a sense of fatigue. The habituation is quiekly

iliahed so that the dose must be increased.

In the Lancet, June 30, 1888, p. 1311, results obtained by Dr. Fischer are

quoted. He found it very successful in the treatment of mania and as a

hypnotic in the dose of gr. TJ0 to fa in distilled water, subcutaneously.

Purely as a hypnotic Fischer discourages its use until other drugs have

:tuse its depressing effect is felt by the whole system.

BBU< I {Deuheker med. Zeitung, March 8, p. 245) has found it most reliable
as a brain sedative, especially valuable in delirium tremens.

■o, chief of insane asylum in Budapest, founds his opinion on several
hundred trials (T/ur. Momatthefte, June, 1888, p. 298) and declares its action in
raving, excited patients extraordinarily successful — a sovereign remedy and far
superior to all known sedatives as respects promptness, reliability and extent
of application. Salgo gives a very exact description of the various steps of its
action. In these cases, however, one may scarcely speak of a genuine, full
sleep — the patients are always sleepy, one finds, and yet always awake. They
may even take their food while under the influence of the hyoscin. Salgo's
dose is gr. fa subcutaneously. From this dose he never saw any bad effects,
either immediate or secondary.

l'i iv.ukn [British Medical Journal, July 14, 1888, p. 75) reports three cases
selected as typical in which he used hyoscine. Case 1, one of delirium
tremens, in a man of thirty-two, full of delusions, trying to escape, etc. ;
on third day, after all sedatives had been tried in vain, hyoscin gr. y^
injected. In ten minutes patient was drowsy, and in twenty the patient
in a sound sleep which lasted nineteen hours; and on awakening his
delusions had vanished. Two other cases were of insomnia and mania, and
hyoscine was equally successful after other drugs had failed. In the case of
mania, hyoscine gr. r£5 brought about a sleep of thirteen hours, and gr. y^^
eleven hours. The general excitement on awakening was lessened. Thus he
has found hyoscine most certain in it.s hypnotic action, but the dose must be
increased, so that if a second dose is likely to be required it is best to com-
mence with gr. ils.

Observation* on Pilocarpine.

Prof. Ma<.nls [8ekmidf$ J.ihrh., 1888, iii. 286), in using pilocarpine as
injection in eye cases, found that in two cases the drug entirely failed when

404 PROGRESS OF MEDICAL SCIENCE.

previously its action had been complete. No explanation could be suggested,
but this accords with the frequent, disappointing failure of this alkaloid as a
diaphoretic.

Antipyrine in Polyuria.

Huchard reported to the Therapeutical Society of Paris (Le Prog. mkL,
May 20th, 417) that in a case of diabetes iusipidus long under observation, he
had succeeded in reducing an amount of twenty-eight quarts to three by the
use of gr. xxx-3J8s of antipyrine; other drugs given as controls proved that
the antipyrine was the effective agent. Again, a simple polyuria of ten quarts
was reduced in five days to half that quantity. A diabetic passing eleven
quarts, after 3jss of antipyrine per day passed only three quarts, and the amount
of sugar was much reduced. In the discussion, Dujardin-Beaumetz said he
had found its use very satisfactory in simple polyuria, giving gr. xxx per day,
but in diabetes mellitus, though the amount of urine and sugar was reduced,
albumin simultaneously appeared.

Eichhorst, (Munch, med. Wochemchr., July 10, 1888, p. 478) saw no good
results from antipyrine in diabetes mellitus, but in a case of diabetes insipidus
an excretion of twenty -six pints was reduced to normal by gr. lxxv, and held
there.

Antipyrine to Suppress Secretion of Milk.
A writer in Bull. gen. de Therap., June 30, 1888, p. 554, claims to have
suppressed the milk in full flow, and after other means had been tried in vain,
by gr. viij of antipyrine, and that in three days' time.

Local Anesthetic Action of Antipyrine Subcutaneously.

Wolff (Ther. Monhft. June, 1888, p. 279) attributes to antipyrine a loci!
action over pain equal if not surpassing that of morphia. In acute rheuma-
tism, au injection in the neighborhood of the affected joint relieved the pain
in three to five minutes, so that — e.g., the patient could without pain raise an
arm that was previously helpless. The chest pains of phthisis he saw relieved
in five minutes and permanently, and the stabbing pains of pleurisy, etc., so
assuaged in a few minutes that a satisfactory examination, previously inter-
fered with by the shallow breathing, was made possible. In muscular rheu-
matism, in a large series of cases, the pain disappeared after a lew minutes,
either not to return at all or in a much more moderate degree. We believe
that it would be useful for purposes of exact diagnosis in all painful exami-
nations— e. g., fresh fractures (vide August number); likewise in neuralgias
of superficial nerves and in asthmatic attacks the results were extremely
satisfactory.

In short, it is of the greatest possible use in all superficial, localized pains
that one wishes to relieve quickly, for its action follows within live mini.
persists ten to twelve hours, ami If then the pain returns, it is much modified.
The solution is made of fifty per cent, strength in boiled distilled water and
filtered several times. A syringeful of gr. viij is given, but oftentimes one-half
the quantity is sullicicnt. No bad effects from the antipyrin were ODten
but locally the injection causes, in all cases, some burning pain, which is often
intense.

MEDICINE. 405

UN Ki>ilts from Use of Phexacetixe.

Given for migraine in a strong, healthy woman gr. xv caused vertigo and
nausea; gr. xv again in three hours, chilly feelings and marked njanosi", with
sweating. Patient could not support herself unassisted. The headache re-
mained unrelieved. The symptoms did not wholly pass off for twelve hours.
— Ther. Monhft., June, 1888, p. 306.

ICHTHYOL.

Ni -sbaum, who has always made much of this substance, has lately praised
its effect on neuralgias and osseous, articular and muscular parts. He uses
pills containing one-sixth of a grain, two b. i. d., increasing rapidly to two,
five times a day. Fischer uses externally in articular pains and psoriasis :

Ichthyol 1

Lanolin 9

In eczema :

Ichthyol 10

Ungt. diachyl 200

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLER, M.D., F.R.C.P. Loxd.,

pkofkmos or clinical medicine in the university oe pennsylvania .
Assisted bt

J. P. Crozer Griffith, M.D., Walter Mexdelsox, M.D.,

ASSISTANT PHTSICIAN TO THE HOSPITAL Or THE PHYSICIAN TO THE ROOSETELT HOSPITAL, OrT-

UNIVERSITT OW PENNSYLVANIA. DOOB DEPARTMENT, NEW YORK.

The Formatiox of Subcutaneous Nodules ix Acute Articular
Rheumatism.

Lindmaxx {Deuttch. med. Wochenschr., 1888, 519) reports two interesting
cases, one in an adult, the other in a child, in which during the course of
articular rheumatism numerous widespread nodules rapidly developed, with
an increase of some of the rheumatic symptoms. The nodules were hard,
somewhat painful, of the size of a pea or bean and movable under the skin,
which was not reddened over them. As the patient recovered from the rheu-
matism the nodules disappeared. The author then makes a thorough review
of the literature of the subject, and collects from it fifty-nine undoubted cases,
of which most were females, and forty six were children. The development
of chorea or of affection of the heart has often been observed simultaneously
with that of the nodules. The latter usually appear suddenly in the later
periods of the rheumatic affection, vary in size from that of a pin-head to
that of an almond, may be symmetrically situated and persist from a few

406 PROGRESS OF MEDICAL SCIENCE.

days to several months, but usually about three weeks. The microscopical
examinations which have been made show the nodules to be composed of
newly formed connective tissue of an inflammatory type. It is possible that
they are of embolic origin with the presence of microbes, analogous to the
vegetations on the valvular leaflets. Their diagnosis should oiler no difficulty.
Kheumatic urticaria and circumscribed oedema are situated in the skin, and
the nodules are in other respects quite different from these, as they are from
the subclavicular pseudo-lipoma of Potain and Verneuil. They may most
easily be confounded with gummata, which, however, become rapidly
attached to the skin, grow larger, soften and often ulcerate; while the peri-
osteal gummata soon assume a periosteal wall. The nodules have sometimes
a diagnostic value, in that they may be the last sign of a slight and forgotten
rheumatism. In such cases they give positive information concerning the
nature of a chorea or an affection of the heart. Treatment is seldom re-
quired.

Abortive Treatment of Whooping-cough.

Mohn, of Christiania (quoted in Centralblatt /. ges. Therap., July, 1888,
p. 441), claims that whooping-cough may be aborted by disinfection of tin-
room by burning sulphur. The patient is moved out, bathed and dressed in
fresh clothes, and the room and all its contents, clothes of patient, etc., fumi-
gated by sulphur for the space of six hours. After proper ventilation the
patient is moved back, and lo ! the whooping-cough is cured in an altogether
miraculous fashion.

The Treatment of Diphtheria with Menthol.

Cholewa (T/trrnp. Monatshefte, 1888, ii. 284) reports most favorable results
from the application of plugs of cotton wet with a twenty per cent, oily solu-
tion of menthol to the nose in cases of nasal diphtheria. In cases in which
syringing of the nose had been impossible on account of its being entirely
filled with membrane, this method seemed rapidly to remove the membrane
and to bring the diphtheritic process to a standstill.

On Perforations in the Skull in Early Childhood.

Henoch [JBerHner Mm, Wor/t, ■„*,/,, -i/t, 1888, 581) contributes an article on
this subject, and describee two cases. He has no reference to craniotabes, or
to eneephalo-meningoeele from congenital defect; but to those forms of
openings which are due to trauma occurring before or after birth, producing
•Imply a depression, or a fracture, or both together. Depression* may be
caused before or during birth by Irregularities in, or narrowness of the
pelvis, the use of the forceps, tetanic labor pains, etc. Trauma toting after

birth commonly produces a fracture or fissure also. These results often

follow falls on tlie bead, whose occurrence the nurse has concealed. Hemor-
rhage over the seat of injury follows, and if the fissure is large enough to
involve s tear of the dura and pia. a "spurious meningocele" is formed.
When the injury la severe, the brain itself is involved, and encephalitis

Which finally terminates in death. The author believes thai at

MEDICINE. 407

least some of the many cases of death preceded by convulsions in young
children soon after birth, and which appear inexplicable, would be found by
autopsy t<> be the result of trauma applied to the head.

Sulphonal ix Insomnia.

it [Neurohg. Centralblatt, 1888, 430) reports the results of 407
administrations of sulphonal to forty-five patients with various mental dis-
orders. 80 times there was no result; 377 times sleep lasting five or more
hours was produced, usually one-quarter to one hour after the medicine had
been taken. The dose varied from one to three grammes. Unpleasant
secondary effects were only observed in one instance, and consisted merely in
some sleepiness on the following morning. The author then instituted ex-
periments to determine whether the drug possessed any disturbing influence
on the diastasic action of saliva, and on the power of artificially prepared
gastric and pancreatic secretions to digest fibrin. The results showed such
power to be absent.

Rabbas {Berliner klin. Wochenschrijl, 1888, 330) has also obtained only
good results with sulphonal in the insomnia of mental disorders. In doses
of two to three grammes it acts better than either amyl hydrate or paralde-
hyde ; and though sleep is produced by chloral more promptly, it does not
last so long. He has found the remedy efficient in the worst maniacal condi-
tions where chloral and paraldehyde had proved unavailing. Most of the
twenty-seven cases to whom the medicament was given 220 times were instances
of mania and melancholia.

Primitive Progressive Myopathy of the Facio-scapulo-humeral

Type.
Interesting in connection with the article of Gray, of which an abstract was
published in the preceding number of the Journal, is an instance of mus-
cular atrophy of the infantile facial type of Landouzy and Dejerine, reported
by Spillmann and Hattshalter (Revue de Midecine, 1888, viii. 451). At
the age of ten years the patient began to suffer from atrophy of the orbicular
muscle of the lips, then of the muscles of the face, at thirteen of the shoulder
and arm, at eighteen of the forearm and thigh. The muscles of the calf and
the flexors of the forearm were spared. The face was expressionless, immo-
bile, with the eyes and lips protruding. The patient stood or walked with
body bent far backward ; the hands were held semi-flexed. The atrophy
attacked the muscles from the outset without a period of hypertrophy ; and in
a portion from a muscle in which the process was far advanced, removed for
microscopical examination, there was found to be simple atrophy without de-
struction of the striation or of the structure. There was no fibrillary contrac-
tion; the electrical contractility was quantitatively diminished in proportion
to the degree of atrophy, but there was no reaction of degeneration. The
plantar and patellar reflexes were abolished — a rare feature in this type of
progressive muscular paralysis, though it may occur when the atrophy is ex-
treme. Although there was wanting in this case one of the most important
symptoms of the affection, namely, an inheritance of the disease, the authors

vol. 96, no. 4.— October, 1888. 27

408 PROGRESS OF MEDICAL SCIENCE.

do not deem this sufficient reason to exclude so well marked an example from
the class of myopathies belonging to the facio-scapulo-humeral (infantile
facial) type.

Dystrophia Muscularis Progressiva.

Erb (MiJnchener vied. Wochenschr., 1888, xxxv. 443) says that in 1883 he
proposed the division of "progressive muscular atrophy" into a spinal form
(amyotrophia spinalis progressiva) and a form which was probably myopathic
(dystrophia muscularis progressiva). In this last division he includes juvenile
muscular atrophy (Erb), the pseudo-hypertrophy of children and the heredi-
tary muscular atrophy (Leyden) and the infantile progressive muscular
atrophy with involvement of the face (Duchenne). He maintains the clinical
unity of the last four forms as regards, namely, localization of the hyper-
trophy and atrophy, the state of the muscles on inspection, palpation and
electrical examination, the fibrillary twitchings, etc. A still stronger proof is
the existence of transitional forms and the numerous cases in which different
forms have been observed in the same family. Observations on portions of
diseased muscle would indicate that the anatomical process is the same
and that the first step is the hypertrophy of the muscle-fibres. There is
found, besides this, all stages of transition to atrophy, the formation of vacuoles,
Assuring, increase of the nuclei, growth of connective tissue and lipomatosis.
The author reserves the discussion of the succession in the anatomical prog-
ress for another occasion.

The Treatment of Diseases of the Lung with the Double Salts
of Caffeine (Sodio-salicylate of Caffeine).

The well-known stimulating action of caffeine on the cardiac and respira-
tory centres has led Ye Gempt (Berlin, klin. Wochenschr., 1888, 504, 527) to
employ it largely in diseases of the lungs. The double salt is to be preferred
on account of its greater solubility and the rapidity with which it is absorbed.
3 grains of the salt per day is seldom sufficient, while over Ih grains per day
is not needed. The number of cases treated was forty. After discussing the
subject fully and reporting some of the cases in detail, the author draws the
following conclusions:

1. The use of the double salt of caffeine is indicated in the course of acute
fibrinous pneumonia whenever observations on the activity of the heart and
the pulse show a diminution in the strength of the heart, a fall of the arterial
pressure or an abnormal frequency or an irregularity of the pulse; the con-
tinuance or increase of which symptoms becomes threatening to life.

'1. The <lrug is to be made use of, when possible, before actual evidenoea of
collapse appear; and if these are suddenly developed, the indication is so
inn. h the more urgent and the effect is still often good.

.:. In oondhioni <>f weakness, valvular lesions, atrophy of the heart, like-
wise in drunkards and in old persons, its employment should be commenced
in tin- beginning of the disease.

4. The action of proper doses consists in diminution of frequency of pulse
and respiration, increase of arterial pressure, lowering of temperature and
favorable action on the subjective sensations of the patient. The use of

MEDICINE. 409

stimulants is not excluded by the administration of caffeine. They are to be
given under the known indications for them.

5. The action of the drug soon commences, but in threatening cases can be
made still quicker and surer by means of subcutaneous injection of the
remedy. After the fall of temperature caffeine is only to be given for a short
time.

(>. The same indications for the use of caffeine hold good in atelectatic or
hypostatic conditions of the lungs.

7. The employment of the double salts of caffeine in emphysema or asth-
matic conditions is indicated by the same signs as those for the use of the
drug in diseases of the heart.

The Treatment of Broncho-pneumonia in Children by the
Application of Ice.

AJTGEL Money (Lancet, 1888, i. 1071) praises the use of the ice-bag in
broncho-pneumonia, having now employed it in many severe cases. To be
successful the treatment must be carried out thoroughly and systematically •
the rectal temperature being the best guide to the application of cold, and
the cause of the broncho-pneumonia having no influence. When a rapid
effect is desired, two ice-hairs may be applied to the head, and one over the
chief seat of consolidation in the lungs. This plan of treatment maintains
the strength of the heart, the respiratory centres, and the nervous and mus-
cular systems ; and convalescence is rendered more rapid. The ice acts not
merely by removing heat, but as a sedative. In this way it produces sleep,
soothes the whole system of motor and sensory centres, and directly and indi-
rectly quiets and steadies the heart and circulation. The beneficial effect upon
the heat centre is well shown by the temj)erature chart; and a piece of ice
applied to one part, especially the head, will produce cooling of the whole
surface. Diarrhoea is not increased by the cold method, vomiting is often
prevented, albuminuria is not rendered worse by it, and no cases of haema-
turia have been seen. The employment of cold does not obviate the necessity
of stimulants, but renders them less necessary.

Tin: Inhalation of Hydrofluoric Acid in Pulmonary Tuberculosis.

Gager (Deutsche med. Wochenschrift, 1888, 594) reviews the literature of
the subject, and the various trials, mostly favorable, which have been made
of the drug in tuberculosis. He then details his experience with 17 cases
I in this manner. In 5 of these the tubercle bacilli disappeared from
the sputum, and there was also decided improvement of the condition of the
lung, as shown by physical exploration ; in 7 there was more or less im-
provement in these physical signs; in 12 an increase of weight was noted ;
in 7 cases there was a gain of 100-600 c.cm. in vital capacity. Of 3 patients
who had fever, one lost it entirely, and another partially. In one instance
nLht-sweats ceased. In 5 cases there was no result. In no instance did the
drug produce unpleasant effects, except in the patients with tuberculosis of
the larynx, where it exercised a distinctly irritating action on the mucous
membrane of that part.

410 PROGRESS OF MEDICAL SCIENCE.

Cardiac Dyspn<ea.

Fraenkel (Berliner klin. Wochenschr., 1888, 289, 815), in an address on this
subject, says that dyspnoea appears in very different forms in the different
heart diseases, depending on the nature of the affection. It is sometimes pre-
monitory, but is then slight and only occasional; and disregarding this, we
rimy distinguish two forms of severe dyspnoea, the continual and the asthmatic.
The first is especially well seen in stenosis of the mitral valve. This lesion is
the least apt to attain complete compensation, and even when this occurs it is
by hypertrophy of the right ventricle and necessarily with overfilling of the
pulmonary system. The distended pulmonary capillaries project into and
narrow the cavity of the alveoli, and this contraction of the alveolar space,
together with the slowing of the blood current, and the lessening of the pro-
portionate surface exposed to oxygenation, produces the continual dyspnoea.
Digitalia In this lesion sometimes acts very badly, since by stimulating the
right ventricle and sending more blood to the lungs it only increases the
shortness of breath. Other cardiac affections also are accompanied by con-
tinual dyspnoea, as for example cases of progressive failure of the left ven-
tricle with consequent engorgement of the pulmonary system ; as is seen in
the last stages of cases of "cardiac overstrain," or in heart diseases resulting
from psychic depression.

Cardiac asthma, on the other hand, Is seen most typically in hypertrophy
of the left ventricle with abnormal resistance in the bloodvessels, resulting
from arterio-sclerosis. The asthmatic attack comes quite suddenly and usu-
ally at night, waking the patient from sleep, and is generally very severe. The
lungs are found full of coarse rales, and respiratory pauses may occur like those
of Cheyne-Stokes respiration. The affection often resembles bronchial asthma
greatly, but may be distinguished by the high tension of the vessels, the ab-
sence of expiratory dyspnoea, and often by the discovery of a dilated left
ventricle, though this is not always easily detected, owing to an IncreaM In the
volume of the lungs. This enlargement is due to the fact that through the
narrowing of the arteries the blood is driven into the venous system, or,
rather, into the lungs and the left auricle. Hence there is a permanent en-
gorgement of the pulmonary circulation, even when there is complete com-
pensation. The sudden asthmatic attacks are probably due to a sudden tem-
porary insufficiency of the left ventricle, brought about by psychic emotion,
increasing catarrh, or Bome other cause. The heart is already doing its
utmost, ami this disturbance of the balance produces increased passive con-
gestion and consequent dyspnoea. Autopsies have shown that the heart
muscle is of normal structure, ami it would, therefore, seem likely that the
failure is due to paralysis of the cardiac nerves or ganglia. Frankel cannot
accept the theory of Haseh, that cardiac dyspnoea is due to a rigidity of the
lungs from their being overfilled with blood ; this producing an insufheiency
oi the respiratory muscles.

Regarding the therapeutics, the author repeats what he has formerly said

in praise of morphia and diiritalis in combination. The former diminishes

the arterial tension, prevents the exhaustion of the respiratory centre by

the continued dyspnoea, and cuts short the asthmatic attack, while the latter

ulates the ventricle to greater activity. Calomel may also be empl.

MEDICINE. 411

fat its diuretic and poxgatiYe action, thus depleting the system; ami though
somewhat uncertain, it always benefits that patient to whom it has formerly
done good. Strophanthushas been of no value in dyspnoea in the author's ex-
perience, except in those cases in which it produces free diuresis. As regards
ur.emie and dyspeptic asthma; the former is simply cardiac, and has nothing
directly to do with uraemia. Cases of the latter have been reported by
Henoch, and seem to depend on the presence of undigested masses in the
ich : the affection being relieved by vomiting after lasting one or two

On the Treatment of Habitual Constipation in Infants.

Eustace Smith Brit. Med. Jottrn., 1888, ii. 7) says that habitual constipa-
tion is very common in bottle-fed children and that even those at the breast are
not exempt from it. The trouble may be due to a deficiency of sugar in the
breast-milk, or to the presence of starch in the diet or to any food which bur-
dens the alimentary canal with a large undigested residue. This sets up a
slight catarrh, and the fecal masses, rendered slimy by the mucus, do not offer
sufficient resistance to the muscular contractions of the intestine. Another
-e is dryness of the stools, this being generally due to an insufficiency of
fluid taken. In either case the colon grows accustomed to the presence of the
fecal mass, and its expulsive power is soon impaired ; while the pain attending
the evacuation causes the child to delay it as long as possible, and the constipa-
tion is thus made more obstinate. It must be borne in mind that the admin-
istration of opium by ignorant parents or unscrupulous nurses is sometimes
at the root of the trouble. Constipation may not at all interfere with the
general health, or it may produce loss of appetite, colic and violent straining
efforts.

When the infant is at the breast a teaspoonful of syrup, three or four times
a day, will often quickly restore the regularity of the bowels. If the stools
are habitually dry and hard and the urine scanty, it is an indication for the
supply of more fluid; and a dessertspoonful of some saline mineral water
given at night aids the return of the stools to their natural consistence. The
form of constipation due to intestinal catarrh may often be remedied by
lessening or removing the starchy matters from the food. Mellin's food is
useful in such cases, particularly if barley water be added to the milk to pre-
vent the formation of a dense curd in the stomach. Benger's "self-digesting
food" is also useful and does not need the barley water, as the pancreatin
digests the curd. When the child has reached the age often months, a little
veal-broth or beef tea is advantageous, or a little well-boiled asparagus or
broccoli, or a teaspoonful of fine oatmeal to thicken the milk. In other cases
the catarrh is due to chilling of the body from insufficient clothing ; and the
remedy is to swathe the belly in flannel and to leave no inch of the surface
of the body uncovered. Frictions of the abdomen following the course of the
colon are to be recommended.

A suppository of castile soap, the injection of forty to sixty drops of gly-
cerin or of half a pint of soap and water will produce an evacuation, but is
by no means curative. To produce a permanent cure such remedies must be
used as regulate the bowels without purging. For this purpose we may em-
ploy a mixture of tincture of nux vomica and tincture of belladonna, with

412 PROGRESS OF MEDICAL SCIENCE.

the infusions of senna and calumba; or one of the fluid extract of cascara
with tincture of belladonna. Haifa grain of sulphur every night is a useful
plan of treatment. When the motions are drier than natural, a valuable
prescription for a baby of six months old is: Sulphate of soda, 5-10 grains ;
sulphate of quinine, \ grain ; tincture of nux vomica, £ drop ; aromatic sul-
phuric acid, 1 minim ; in a teaspoonful of water three times a day before
food. This draught does not teach the bowel to depend upon it, but to act
spontaneously, so that the frequency of administration can be diminished
and the medicine finally discontinued.

The Diagnosis of Abdominal Tumors.

For two years O. Minkowski (Berlin, klin. Woclmischr., 1888, 617) has
been devoting his attention to the diagnosis of abdominal tumors chiefly by
observing the changes in position which they undergo, if, on the one hand,
the stomach be distended with carbonic acid gas, or, on the other hand, the
large intestine be filled with water. The position of the tumor is first deter-
mined accurately, the stomach being as empty as possible ; carbonate of soda
U then administered to the patient and followed by tartaric acid, and the
stomach in this way distended with gas. The position of the tumor is thin
again accurately mapped out. The gas is then removed by the stomach tube,
the large intestine filled with water by injection — which is to be preferred to
its distention with gas — and the tumor again outlined. The author has exam-
ined 110 abdominal tumors in this way, and has found that, on thus distending
the stomach or intestine the growth tended to move toward the region which
the organ would occupy under normal conditions. 1. Tumors of the liver
more upward and to the right when the stomach is distended with gas. On
filling the intestine the growth moves upward simply; sometimes slightly to
the right or left. 2. Tumors of the gall-bladder follow much the same rule
as applies to those of the liver. 3. Tumors of the spleen move to the left
and often slightly downward on distending the stomach. On distention of
tin colon they move upward and usually to the left. Movable tumors of the
spleen, which have left the normal position, tend to resume it when the
stomach, and especially the intestine, is dilated, and to produce again the
splenic dulness which had been absent. The filling of the stomach with gas
is a very valuable means of distinguishing between an enlarged left lobe of
the liver and an enlarged spleen. 4. Tumors of the stomach can often be
r.-< ■ognized at once when the stomach is inflated. In other cases the fact
that the growth becomes broader, the boundaries more indistinct, the percus-
sion round more tympanitic and isolated nodules more widely separated from
i other indicates that the growth belongs to the stomach. Circumscribed
tumors in the region of the pylorus usually move to the right and downward,
rumors of the transverse colon and of the omentum also often exhibit the
MOM ehftnge of position when the stomach is inflated, but in many cases the
growths of the stomach can be distinguished by the fact that they move in
an upward direction when the colon is filled with water. Growths of the
lesser curvature usually move upward end disappear backward when either
the stomach or colon is distended; but they are subject to other changes of
ion. .">. Tumors of the colon arc often easily recognized, becoming
broader when the intestine is filled with water. Tumors of the transverse

SURGERY. 413

colon move upward on inflation of the stomach, but downward on distention
of the ooloo. It is to be noted, however, that growths of the intestine often
offer the greatest difficulty in their recognition. 6. Tumors of the omentum
are displaced downward by inflation of the stomach, and downward and
riirly forward by the filling of the intestines. 7. Tumors of the kidney
are not materially affected by inflation of the stomach, but move upward on
distention of the colon, are felt with difficulty, and then almost always disap-
pear. If the abdominal walls are flaccid, the intestine filled with water can
often be quite easily traced in its course over the tumor. If the kidney is not
in its normal position, as is so often the case, the injection of water into the
intestine will usually push it into its proper place. Very large renal tumors
do not entirely disappear in this way, but are very distinctly pressed outward
and backward. 8. In a case of tumor of the pancreas the growth acted much
as did those of the kidney, except that on distention of the stomach there
was a slight displacement toward the right. 9. Tumors of the ovary are
moved by the full intestine forward, a little upward and to the side to which
the diseased ovary belongs.

The author recommends that in the investigation of abdominal tumors the
inspection of the patient from behind be not neglected. Tumors of the liver
or spleen will show a prominence at the lower part of the thorax, and those
of the kidney, if of considerable size, at the middle of the lumbar region,
seldom, however, in the case of growth of the kidney, there will be a
depression or diminished resistance of the soft parts in this region. In such
cases an evident projection will appear here, when the colon is filled with
water. This is one of the most constant symptoms of movable kidney, or of
movable renal tumors. Trousseau's method of bimanual palpation may be
with advantage applied to the examination of tumors of the liver, spleen and
intestine, as well as of the kidney. In many cases, in which a tumor of the
kidney cannot be detected in this way, the growth may be felt after the colon
has been distended with water and the kidney restored to its normal position.
As is well known, the recognition of tumors by their displacement by respira-
ration is often disappointing, since growths of all the abdominal viscera may
sometimes move when the patient breathes. In such cases a decision may be
reached by fixing the tumor from outside during inspiration. If it is a tumor
of the liver, or one adherent to this organ, the expiratory movement upward
cannot be thus prevented.

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

■CK4EOX TO THB PHILADELPHIA AND OERKAX HOSPITALS; CUBICAL PROrr.-W.lR OF OEXITO-URISART
■UEOERT IX TH« CXIYRMITT Of PE.NS8TLYAXIA.

INTESTINO- PERITONEAL SEPTICAEMIA.

Under this name Verchere {Revue de Chirurgie, No. 7, 1888) describes, in
an exceedingly able article, an affection either not mentioned by surgical
writers or classed as a latent peritonitis.

414 PROGRESS OF MEDICAL SCIENCE.

All legions of the abdomen, accidental, surgical, with or without injury to
viscera, may exhibit the typical symptoms of the condition. These symptoms
are : an exceedingly rapid and marked meteorism, a profound alteration in
the expression, absence of tenderness on pressure, more or less retention of
gas and fecal matter, a normal or subnormal temperature during the entire
course of the affection till shortly before death, when the thermometer shows
a sudden increase of temperature to 103°-104°. The pulse is small and very
frequent. There is vomiting, usually bilious, at times, stercoraceous. Nausea
and regurgitation almost from the beginning. Anorexia absolute. Thirst
intense.

The autopsy shows none of the lesions belonging to peritonitis. There is an
active congestion of the peritoneum. Sometimes a small quantity of brownish
fetid effusion, sometimes gas. The intestinal distention is considerable. Putre-
faction is very rapid. The affection runs its course in eight, ten, or twelve
days. Sometimes for the first three or four days the abdominal facies, meteor-
ism and constipation will be the only symptoms, then all the grave phenomena
quickly appear, and death follows shortly.

These identical symptoms are characteristic of all forms of intestinal occlu-
sion, strangulated hernia or internal strangulation. Similar symptoms are
dependent on similar causes. The cause in the so-called latent peritonitis is
referable to pseudo-strangulation. At first the phenomena of peritonism
(reflex paralysis) develop ; then a mechanical occlusion by flexure of the in-
flated intestine, from which follows absorption of the septic intestinal contents
and intestino-peritoneal septicaemia.

The diagnosis is evident in the majority of cases, and it is necessary to
differentiate this distinct morbid process from peritonitis with which it has
always been confounded. The therapeutic indications depend naturally upon
the primitive cause.

Gastroenterostomy.

Two successful cases of gastroenterostomy are reported by Fritsche ( Gorre-
spondenz- Watt filr Schweitzer Aertze, No. 15, 1888). These, together with Lucke's
eight successful cases, considerably reduce the mortality of this operation.
Gastroenterostomy is indicated in cicatricial or malignant pyloric obstruction.
In the one case it promises a speedy cure with the minimum of danger, in the
other, a complete subsidence of all painful symptoms, and months of enjoy-
able life. One of Lucke's case s survived the operation for more than a year.

Fritsche operated after Wolfler's method. Preparatory nutrient enemata
and washing out of the stomach, followed by a one-half per cent, salicylic
acid lavage. Median incision, four inches in length, from the ensif'onn carti-
lage, downward. A loop from the upper portion of the jejunum, sufficiently
free in its attachment to be brought in apposition with the anterior wall of
the stomach, was selected. A portion, about a foot and a half from the termi-
nal ion of the duodenum, was chosen for the opening, and loosely tied off from
tin- remaining gut by two pieces of disinfected cotton bandage passed through
a non-vas.-iilar part of the mesentery. A portion of the anterior stomach wall
was compressed between two iron rods protected by rubber tubes, and held
together by elastic bands passed about their ends. The incision was two

SURGERY. 415

inches in length, and was made first into the bowel; its upper borders were
sutured to the peritoneal coat of the stomach, after which the latter was
opened and secured to the bowel by a continuous mucous membrane suture,
a continuous Czerny suture, including the muscular and serous coats, finally,
a continuous Lembert suture. A portion of the bowel proximal to the fistula
was secured to the stomach wall by a few threads. The abdominal wound
was closed by a continuous peritoneal suture, a muscle and fascia suture,
finally, a skin suture. Of the two cases treated, one suffered from pyloric
cancer, the other from stricture in the same region. In the after-treatment,
the only complication was due to yielding of the catgut parietal sutures.

Excepting cases of pyloric cancer whicn have contracted no adhesions, are
limited in extent, and have not involved the glands, gastroenterostomy is
always to be preferred to pylorectomy. The choice of this operation in cica-
tricial contraction rests upon the fact that its mortality in these cases is 14.3
per cent, against 57 per cent, for pylorectomy.

The secondary dangers of gastroenterostomy are, spur formation which may
completely obstruct the fistula, and compression of the colon by the mesentery
of the bowel containing the fistulous opening. Death has followed from both
of these sequelae, with symptoms of ileus.

The Surgical Treatment of Ulcerative Perforation* of the
Stomach and Bowels.

Steixthal [Beilage zum Oentralblait fur Chirurg., 1888, No. 24) reports
three cases of ulcerative peritonitis operated on by Czerny unsuccessfully.

Que I. — Servant, aged twenty. Frequently a sufferer from pains in the
stomach. Five days before operation pain suddenly developed in the left
side. The following day abdominal swelling and dyspnoea. Since then great
constitutional disturbance, no stools, no vomiting; on examination, belly
swollen, tender and tympanitic, no liver dulness, some impairment of reson-
ance in the lumbar region.

Operation. Incision in the middle line; on opening the peritoneum escape
of a quantity of odorless gas. Peritonitis slight. Perforation could not be
found. Death in four days.

Autopsy showed a perforation of the anterior wall of the stomach.

Case II. — Waiter, aged thirty-three. A chronic sufferer from pains in the
stomach. Three days before operation, after a sudden movement, pain was
immediately felt a hand's breadth to the right of the navel, with the sensa-
tion of something having given way. Continued vomiting since. Neither
gas nor feces by the rectum. Belly greatly swollen, especially in the epigas-
tric and hypogastric regions. Tenderness over the whole abdominal region,
but most marked on the right side. Some percussion dulness in lumbar
region, extending a hand's breadth above Poupart's ligament to the middle
line. Resonance over the liver.

Operation. Incision in the middle line. Offensive gas discharged on open-
ing the peritoneal cavity. Dull percussion sound over Poupart's ligament,
explained by a pericecal abscess. Perforation found at the pyloric orifice
of the stomach. Sutured. Death the same night.

416 PROGRESS OF MEDICAL SCIENCE.

Autopsy. Diffuse fibrinous peritonitis ; ulcerative perforation by a chronic
ulcer of the stomach, with circumscribed peritonitis.

Case III. — Man, aged fifty-two. Woke in the morning with pain in the
caecal region. Rest in bed, ice-bladder, liquid diet following. On the second
day after, sudden and violent pain in the ilio-caecal region, collapse. Swell-
ing of the belly, gradually diminishing percussion dulness of the left lobe
of the liver. Swelling and resistance in the ilio-caecal region, with a circum-
scribed percussion dulness somewhat larger than a silver dollar.

Operation. Incision in the ilio-caecal region. No escape of gas. Resection
of a perforated necrotic vermiform appendix. Symptoms all favorable till
the fifth day, when restlessness, swelling, nausea, vomiting and collapse ap-
peared. Death the next day.

Autopsy. No general peritonitis. Intestines greatly distended.

Of eighteen cases operated on for ulcerative perforation, eight were cured.
In five of these eight there was a circumscribed sacculated peritonitis, which
was incised and treated as an abscess, with suture of the bowel in one case,
and resection of a necrotic vermiform process in another. In the remaining
three cases, in addition to the perforation, there was diffuse suppurative
peritonitis.

An early diagnosis is a most important element in the prognosis.

In addition to the history, sudden development of peritonitis, with uni-
versal tympany, indicates a perforation. If there is rapid development of
tympany, with disappearance of the liver dulness, and, on opening the cavity,
odorless gas escapes, the perforation is probably in the stomach. Perforation
of the ilium^or colon is characterized by foul, septic gas. In perforation of
the jejunum there is slow escape of contents and gradual development of
symptoms.

In these operations the peritoneal cavity should be irrigated by one-sixth
per cent, salicylic solution till it comes away clear. The most extensively
infected portion of the bowel is treated with bichloride solution. Lowen-
stein believes that a thorough purification of the peritoneal cavity after per-
foration is impossible and dangerous. According to Frank, Hahn has
operated twice for typhoid ulcerative perforation; both cases were unsuc-
cessful.

Wagner reports an operation in the case of a man who had ruptured a
duodenal ulcer by lifting a weight. The diagnosis of intra-peritoneal rupture
of the bladder was made. The seat of perforation was found at the autopsy.

Radical Operation for Reducible Hernia.

Cohn {Berlin. /:/in. Wochenschr., No. 32, 1888), reports 51 cases of reducible
hernia, for the cure of which a radical operation was undertaken. Of this
number 41 wore inguinal. '.» antral, 1 umbilical. The operation consisted in
closing the hernial opening by a double catgut ligature, after which the sac
was extirpated I lertain difficult and advance. 1 cases required the insertion of
additional sutures, the approximation of the columns of the ring, etc. In
most of the cases the wound was closed by a catgut suture and rubber or glass
drainage tubes inserted. Under certain conditions the wound was peeked,
ami subsequently closed by secondary suture. In women and children satura-

SURGERY. 417

tion of the dressings by urine cannot always be avoided, the tamponade is
especially to be commended when this is liable to occur, not because it abso-
lutely prevents septic infection but because it allows of immediate treatment
and purification.

Since primary union is frequently prevented by a certain amount of con-
nective tissue-destruction, and since consecutive bleeding is by no means rare,
there would seem to he, in these cases, special indications for tamponade and
secondary suture. Though the wound is longer in healing, the cicatrix is
larger and more dense. The results were most satisfactory in the cases treated
by this method. Large pieces of iodoform gauze were used.

If no fever is developed, the packing is removed in six days, and unless there
are necrotic shreds of connecti\v-tU>ue, the wound is closed by a silk suture.
A thin layer of irauze, the end of which projects from the lower angle of the
wound, provides for drainage; this is usually removed at the next dressing
(eighth day). When necrotic tissue is slow in coming away the wound is not
sutured, but allowed to close by granulation. The sutures can be inserted
and loosely knotted at the first operation, to be tightened when the packing
is taken away. After cicatrization the patient wears a truss.

The only contraindication to the operation is an incurable intercurrent

ise, such as carcinoma or advanced phthisis. Extremes of age or immense

hernial bulk should not weigh against an effort to secure a radical cure. The

danger is so slight that every patient suffering from hernia should be advised

to submit to an operation.

• the permanency of the cure, but five cases were investigated. Three
of these have not suffered from a return of the protrusion. In the first case a
year has passed since the operation, in the second and third cases but a few
months. Of the forty -eight patients treated, but one perished as a direct con-
sequence of the operation ; in this case acute septicaemia developed.

Sterility in Mil

Ft'RBBiXGEK {Deutsch. medicin. Wochensch., Xo. 28) classes the conditions
which exist in sterile men under two headings. There may be absence of
spermatozoa or absence of seminal discharge. Absence of spermatozoa is the
most frequent cause of sterility among men. This condition is rarely -
pected since coition may be complete, and accompanied by an abundant
seminal discharge. After an extended clinical investigation Furbringer con-
cludes that in all cases of procreative impotence there is permanent azoo-
spermatism, and that the cause of this absence of spermatozoa in the semen
is (with few exceptions) an obliteration of the seminal duct due to a double
gonorrhceal epididymitis or funiculitis Since Kehrer found, in forty cases
of matrimonial sterility, that the cause lay with the man in fourteen, since
coition and ejaculation on his part are, by himself and by the physician,
n as evidence of his competency, and consequently fruitful women are
subject to tedious cures and gynecological operations, Furbringer strongly
insists on the most careful examination of the husband, and on the micro-
nation of his ejaculation in all such cases. The prognosis is
absolutely bad in cases which have lasted longer than three months. In
aspermatism there is no ejaculation. The permanent form is caused either

418 PROGRESS OF MEDICAL SCIENCE.

by a displacement of the ejaculatory duct by which the secretion is carried
toward the bladder, or by a well-marked stricture of the urethra. In the
latter case an erection may make a stricture entirely impermeable which,
under ordinary circumstances, allows of the passage of a moderately full
stream.

Fiirbringer observes that the prostatic secretion is the source of the strong
seminal odor, the secretion of the testicle being absolutely odorless. The
statement is made that the spermatozoa show motion only when mingled with
the prostatic fluid.

Cholecystenterostomy.

Chlolecystenterostoray, proposed by Nussbaum, but first successfully per-
formed by Kappeler, has again succeeded in the hands of Socin (Correspondez-
blattfur Schweitzer JErtze 15, 88).

The patient, set. fifty-one, had been seized with abdominal pains eleven
weeks before the operation, and had shortly become jaundiced. Pain only
during digestion. Loss of strength and weight rapidly progressive. On ex-
amination marked bronzing of skin and mucous membranes, dryness of the
surface, advanced emaciation. The liver extended downward to within a
third of an inch of the anterior superior spinous process of the ileum.
Beneath its edge was felt a rounded, smooth, fluctuating, slightly tender
swelling, the size of a man's fist, movable laterally. Urine contains bile ; the
stools showed no sign of its presence. Temperature subfebrile. Weight ninety
pounds. Obstruction to ductus communis choledochus was diagnosed.

Operation : Free incision along the border of the rectus. The peritoneal
cavity was opened, the gall-bladder readily drawn forward, opened, and a
pint of gall evacuated. Since neither gall-stone nor any other obstruction
was found, a cholecystenterostomy was determined upon. The jejunum was
drawn out, an incision an inch and a quarter long made in it, and this opening
sewed to that in the gall-bladder. Passage, containing bile, in three days,
disappearance of icterus, and in a month a gain of nine pounds.

The Diagnostic Significance of a Tongue-like Extension of the
Right Lobe of the Liver, in Diseases of the Gall-bladder.

Riedkl [Berliner klin. Woekenechr., No. 29) describes a tongue-like projec-
tion of the right lobe of the liver, extending downward, which is sufficiently
frequent to be an important aid in the diagnosis of certain obscure inflamma-
tory affections of the gall-bladder. By palpation it can readily be felt as a
smooth resisting body, continuous with the liver, moving in respiration, and
frequently extending below the level of the umbilicus. The percussion note
may be resonant, ihowing that the depth of the out-growth is not great. In
six. often cases, the extension was most marked, and in two cases constituted
tin- main diagnostic point.

As to the value of this sign, in itself it is not to be depended upon as indi-
cating involvement of the gall-bladder, since it is found in other inflammatory
enlargements which become attached to the liver by circumscribed adhesions
(cystonephrosis) or may develop Independently of inflammation from con-
striction (corset liver).

SURGERY. 419

If, however, there is found beneath this outgrowth an area which is pain-
ful, or is tender on pressure, if there is a history of hepatic colic, or of severe
attacks of vomiting, this peculiar extension of the liver is a confirmatory sign
of great significance.

Of the ten cases operated on for inflammation of the gall-bladder, seven are
entirely healed, one is in process of healing, and two are left with fistulae.
The discharge in these two cases is very slight.

Suturing of the gall-bladder in the abdominal wound, and subsequently
opening it, is commended as an entirely safe operation.

Riedel's technique is as follows :

For two days attention is paid to clearing the bowels. Immediately before
the operation a morphia injection is given to make the anaesthetization as
quiet and complete as possible. The incision is made over the swelling,
through the rectus muscle, if possible, separating its fasciculi. It should be
small, an inch and a half to two inches in length. After division of the
transversalis fascia and the peritoneum the gall-bladder is seen covered by
omentum which must be pushed aside. After exploration, by means of the
finger thrust into the peritoneal cavity, an oval surface of the gull-bladder,
three-fourths of an inch long by one-fourth in breadth, is united to the peri-
toneum by six or eight catgut sutures threaded in round needles without
edged points. These sutures are passed only through the outer coat of the
gall-bladder; this is easy as the walls are much thickened by inflammatory
action. In the middle of the oval a silk thread is inserted. This is most im-
portant as, after six or eight days, the whole wound is covered with a mass of
granulations, and, without some certain guide, opening the gall bladder might
be exceedingly difficult. The wound should not be wedge-shaped at the time
of secondary incision but should be, at its deepest part, as broad and long as
at the surface, and should expose the entire oval. To accomplish this, small
dossils of recently sterilized gauze are packed around the central silk thread
to the very bottom of the wound. These dossils are removed in eight days,
when an incision, three quarters of an inch long, is made where the silk
thread is attached. The incision is gradually deepened, the edges of the
wound being held apart by hooks, till the knife enters the gall-bladder. An
exploration is now made by the finger, large stones are crushed and removed
by a spoon, smaller stones are washed out. The dressing must be changed
frequently ,at first, as there is usually a profuse flow of gall. The skin about
the drainage tube is protected by ointments. In three or four weeks the dis-
charge diminishes. In five or six weeks the drainage tube is taken out. The
cicatricial tissue quickly contracts, and the patient requires no dressing.
From the fact that there is rarely any immediate urgency in cholecystotomy,
that the secondary incision requires the minimum exposure of the peritoneal
cavity, and is completed in a few minutes, this double operation is advised in
all cases of cholelithiasis and inflammation, except in cicatricial obstruction
of the cystic duct, or in case of stone so firmly secured in a diverticulum or
in the cystic duct that it cannot be dislodged, when cholecystectomy is in-
dicated.

Suture of a:x Old Patellar Fracture.

Sonxenbubg {Beilag. sum Centralblatt fur Chirxmj., No. 24, 1888) records
the case of a patient, who, in 1884, fractured his patella and recovered with

420 PROGRESS OF MEDICAL SCIENCE.

ligamentous union. In 1887 the ligamentous band was torn and the frag-
ments widely separated. As there was no chance for spontaneous union and
the quadriceps was somewhat atrophic, Sonnenburg determined upon approxi-
mation and suturing of the fragments after v. Bergmann's method. The
tuberosity of the tibia was chiselled off to allow the lower fragment to be
approximated to the upper ; in spite of this, it was very difficult to suture
the two fragments closely to each other. The case terminated favorably.
Bony union took place, the quadriceps became again functionally active, the
patient could extend his leg and flex it to a right angle. Sonnenburg con-
siders this the best method by which widely separated fragments can be
approximated, but cautions the surgeon against involving the joint in the
separation of the tuberosity.

The Checking of Hemorrhage in Amputations of the
Shoulder-joint.

In case of traumatic or inflammatory affections calling for shoulder-joint
amputations, W. Koch (Archivfiir klinuch Chirurg., xxxvii. Bd., Heft 2) holds
that the management of hemorrhage is attended with little difficulty. Bleed-
ing is insignificant, even though circular compression and pressure upon the
subclavian be omitted, if the operator proceeds in the ordinary method — i. e.,
a vertical incision running down from the coracoid process, disarticulation,
seizure of the axillary artery by the fingers of an assistant, and completion of
the Haps by a circular cut. If the operator prefers, a preliminary ligation of
the third part of the axillary may be performed.

In the profound anaemia always attendant upon malignant sarcoma of the
arm or shoulder, whether the tumor be ulcerating or not, the loss of a rela-
tively small quantity of blood becomes a very serious matter, and the hemor-
rhage, even after a preliminary ligation of the axillary or subclavian is extra-
ordinarily profuse.

In these eases Koch advises that the clavicle be divided at the inner border
of its outer third and, after a preliminary bandaging of the arm, a strong rub-
ber tube be passed beneath the axilla, around the shoulder and through this
Wreak in the continuity of the bone. Before knotting, four loops should
be affixed, corresponding to the position of the pectoralis, latissimus dorsi,
claviele and spine of the scapula. The rubber tube is drawn tight and tied,
and to prevent it from slipping when the arm is taken away the loops are
palled by two assistants toward the sound side of the body. By this means
not only the subclavian but also the vessels which supply the collateral circu-
lation are firmly <■. impressed.

Tin: Treatment of Fractures of the Elbow-joim.

Lai Dnm [Bdlag. mm OmkmlMatt /Or CMrurg., No. 24, 1888) advices
ipra-eondyloid, condyloid or T-t'raetures of the lower extremity of the

bnmeras, treatment in the extended position, on the ground that displacement

of the oondyles cannot be detected when these fractures are treated opOfl the
ordinary right-angled splint, but will, when union is complete, leave the patient
with an axil deformity, on extension, corresponding to varus and valgus, as the

r or outer condyle is displaced. Since ankylosis is frequently due to

DERMATOLOGY. 421

an over-production of callus, this accident is favored by a position which
will not allow the surgeon to determine certainly whether or not the bones
are in proper position. Lauenstein has treated all of his cases for the last
trs in the extended position, and has had excellent results.

Kfoig, while commending the extended position in hospital practice, holds
that the angular splint is more practical for private and dispensary patients.

Bardenheuer has for five years treated all elbow fractures with permanent
extension, both longitudinal and transverse, and with satisfactory results.

ier and Sonnenburg, while admitttng the value of this method, claim
that some cases do better when treated in the right-angled position.

Massage Treatment of Chronic Leg Ulcers.

Appenrodt (Deutsch. medicin. Wochenschr.) commends massage as a means
of treating chronic, indurated, eczematous leg ulcers which have resisted all
other treatment, claiming the rapid appearance of healthy granulations and
prompt cicatrization as the certain sequence of perseverance in this method.

The ulcer and the entire limb must first be thoroughly disinfected by a
course of antiseptic dressings and washings, lasting for several days ; other-
septic matter may be forced along the lymphatic channels and multiple
abscesses complicate the case.

Light effleurage is first employed carefully, avoiding strong pressure. Lan-
olin is used as the inunction. After massage, the limb is again thoroughly
washed with soap and disinfected ; all raw surfaces are dressed with mull
spread with lanolin, covered with tissue paper, and a roller bandage applied
over the whole.

DERMATOLOGY.

UNDER THE CHARGE OF

LOUIS A. DUHRIXG, M.D.,

PROFESSOR OP DERMATOLOGY IX THE UNIVERSITY OP PEXX8YLVANI A ;
AND

HENRY W. STELWAGON, M.D.,

PHYSICIAN TO THE PHILADELPHIA DISPENSARY FOR SKIM DISEASES.

Pemphigus Pruriginostjs— Cure by Carbolic Acid.

The notes of a case of pemphigus pruriginosus treated successfully by
applications of carbolized water are given (Bevue M So. 4, 1888) by

i.ETAN. The patient, an adult male, exhibited upon all parts variously
sized blebs in the several stages of development. The lesions covered, in all,
more than half the surface. The eruption appeared in outbreaks, accom-
panied by elevation of temperature. As soon as one crop had about disap-
peared, a recurrence would take place. The patient was greatly enfeebled,
both by the direct draining effect of the disease, as well as by the intense

•122 PROGRESS OF MEDICAL SCIENCE.

and persistent itching. The ordinary therapeutic methods were tried in vain,
and, finally, as a palliative to the pruritus, compresses wet with carbolized
water (one per cent.) were applied, with almost instant relief to the itching,
and with gradual improvement in all the cutaneous symptoms. The new
blebs were abortive, and in four or five weeks after these applications had
been ordered, the patient was discharged from the hospital cured. In the
beginning of this treatment, especially when there were numerous excoria-
tions, it was necessary to discontinue the applications, for hours or days,
by reason of evidences of toxic influence. In all, the case was under treat-
ment, from admission to discharge, from the middle of January to the last
of March. The disease had made its appearance early in the preceding
December. The author suggests that the therapeutic result of the carbolic
acid applications agrees with the microbe theory of the disease advanced by
Gibier.

Pemphigoid Eruption, with Changes in the Peripheral Nerves.
Sangster and Mott read before the Royal Medical and Chirurgical
Society [British Medical Journal, June 16, 1888) the notes of a case of pem-
phigoid eruption, with rapidly fatal termination. The patient, aged seventy-
eight, when admitted to the hospital, was, to a large extent, covered with a
bullous eruption of fairly symmetrical distribution and was, moreover, as to
general condition, exceedingly prostrated, with an elevated temperature.
The patient was evidently suffering from renal disease, as the urine was
scanty and loaded with albumen. Nineteen days after admission, death
ensued, being preceded in the last three days by uraemic symptoms. A micro-
scopical examination of hardened sections of the cutaneous nerve and also
of the spinal ganglia and posterior roots showed a parenchymatous degenera-
tion of the nerve fibres. [The duration of the disease before admission is
not stated. — Eds.]

Recurrent Herpes zoster Femoralis.

A case of a tropho-neurotic eruption recurring at intervals is reported
{Monatthe/te J'ilr pr<i klisihe Dermatologie, No. 11, 1888) by During. The first
outbreak had been preceded three months previously by a severe septic
phlegmonitis of the left thigh. Following this phlegmonitis, and before the
peculiar herpetic eruption manifested itself, there had been in the same
region, at intervals of weeks, an erysipelatous-like inflammation ; redness
and swelling constituting the local symptoms. These attacks were of briet
duration, and excepting the fifft, unaccompanied by any constitutional dis-
turbance. Later the eruption assumed a distinctly herpetic character and
corresponded to the course and distribution of the anterior branch of the exter-
nal cutaneous nerve. Each of these herpetic attacks lasted about six weeks.
;m outbreak being preceded, for several days, by general symptoms of malaise
and elevation of temperature. Several weeks or months would intervene
between these herpetic outbreaks. Seabathing appeared to have an influ-
ence in delaying a recurrence. An attack of typhoid fever, also, gave several
months' relict from the eruption. In the past year, the patient has also suf-
i from attacks of herpes proeputialis. and these seemed to be, in a sense,

DERMATOLOGY. 423

vicarious, as the intervals between the recurrences on the thigh were, during
this period, much longer. The patient came under observation in 1881 and
up to the present time is still a subject of these attacks.

On the Treatment of Lupus.

As an auxiliary to the ordinary methods of treating lupus, or as an inde-
pendent method, Unna advises (Monatshefte fur praktiictie Dermatologie, No.
\. 1S88) the following lotion: R. Corrosive sublimate, 1; carbolic acid or
creasote, 4; alcohol, 20. The nodules are attacked in series of tens, begin-
ning with those at the edge of the patch. They are first punctured with an
acne lance, and a minute shred of absorbent cotton moistened with the lotion
is inserted by means of a sharpened stick ; the cotton rotated and allowed to
remain for ten or fifteen minutes. In a few days the punctures and lupus
deposits so treated have almost disappeared, and other nodules may be then
similarly attacked. This method, the writer believes, has many advantages
over the somewhat similar plan of treatment by means of the nitrate of silver
stick.

On the Treatment of Sebaceous Tumors.

T. Murray Robertson states (British MedioalJoumal, June 2, 1888) that
in consequence of the objection of many persons with congenital sebaceous
tumors and "wens" to the ordinary surgical methods of removal, he has
adopted in such cases the following simple plan with marked success: The
cyst is punctured with a Grafe cataract knife and the contents gently ex-
pressed, and then a very small piece of silver nitrate introduced. The follow-
ing day the capsule of the cyst may be readily removed by means of a pair
of forceps, coming away " like the shell of a bean," without any part being
left adherent. No ill effects have been noted, and a regrowth has not been
observed.

Urticaria Pigmentosa.

In the case reported by Elsenbero ( Vierteljahressehrift filr Dermatologie
i/ti't Syphilis, Heft 3, 1888) the disease began when the child was six weeks
old, and to the time of this report, two years subsequently, it was still per-
it. The lesions at first were of the well-known rosy tinge, but soon
showed a brownish coloration. The older efflorescences were of a decided
olive hue, and the skin, which had been the seat of recurring wheals, was
more or less darkly pigmented. The itching, somewhat variable as to degree,
was the most annoying symptom. The child was healthy and in spite of the
disease remained well-nourished. There was nothing in the family history to
throw light upon the case. From time to time the tongue was the seat of
whitish, rounded, sharply defined plaques, from which the epithelium exfoli-
ated, leaving red excoriations. Arsenic and sodium salicylate were each perse-
veringly prescribed, but with negative effect. In the last month in which the
child was under observation atropia was given and with considerable benefit.
Externally, warm baths, salicylic acid and carbolic acid ointments afforded
some relief to the itching.

vol. 96, so. 4.— October, 1888. 28

42-i PROGRESS OF MEDICAL SCIENCE.

Post-vaccinal Eruption.

Behrend reports briefly [Berliner Wnitche Wochcnschrift, No. 26, 1888) an
eruption, more or less general, following vaccination, in a child eight months
old. The lesions, which at first were distinctly papular, changed to urticaria-
like spots, and around many appeared a vesicular wall. In places, the erup-
tion became confluent, forming solid sheets, which near the flexures, especially
about the genitalia and the anal region, became superficially eroded. In fact,
when fully developed, the eruption presented phases of several affections —
urticaria, erythema multiforme and herpes iris. The writer again calls atten-
tion to a fact to which he had referred several years previously : that in vac-
cinal eruptions there seem to be two periods for their occurrence — either in
the first three days or not until the eighth or ninth day. In the present case
the eruption appeared on the eighth day.

Transplantation of Carcinomatous Skin.

An interesting experiment {Berliner klinische Wochenachrtft, No. 21, 1888)
regarding the effect of transplantation of carcinomatous skin has been made by
Hahn. The patient, who had some time previously been operated upon for
mammary carcinoma, applied for relief for severe pain and the reappearing car-
cinomatous deposits. In the neighborhood of the scar had appeared a hard, dif-
fused infiltration and here and there numerous scattered nodules. By reason
of the great extent involved and the debilitated condition of the patient,
another radical operation was inadvisable, and the experiment was made of
excising, in a few places, portions of the affected skin, replacing it by healthy
integument from the adjacent parts, and recovering these latter bare places
with the excised portions of the carcinomatous skin. The parts healed, but
the healthy tissue surrounding the transplanted skin, as a result, became
involved in the carcinomatous process.

Acute Circumscribed CEdema of the Skin.

Several cases are reported ( Wiener medicinixche I*reMe, Nos. 11, 12 and 18,
1888) by Kn.11 1.. An analysis of the various cases permits the symptoms t<>
be roughly grouped as follows: 1. Evanescent oedema of the skin, subcu-
taneous tissue and mucous membranes. 2. Stomachic, intestinal (and rami
disturbances. 3. General symptoms, such as depression, somnolence, etc. ;
and a fourth group might be added, which would include respiratory disturb-
ances. As yet, the cause of these complex syiuptonis is, as the author remarks,
unknown. The arthritic diathesis has been stated (Chaffart) to be responsi-
ble; others look upon the different symptoms as doe to regional oedema, as,
for example, vomiting, as being due to oedema of the walls of the stomaeh.
Others again, including the author, consider it extremely probable that while
the various symptoms are directly <luo to regional oedema, the exciting cause
of these peripheral vasomotor disturbances is to be found in the central
nervi > .

Mi i/ni'i.E Circumscribed Gangrene of thi: skin.
Hamburg M Society [M&nchtner mcUdnie!, 11

tchri/t. No. 21, 1888 A i:\1\0 exhibited a girl of fl -ince

DERMATOLOGY. 425

eight days previously, had been affected with a peculiar eruption of a gan-
grenous type. On the face, right shoulder, right thigh and left forearm
were to be seen small, sharply defined, gangrenous patches, superficial in
character. They had their beginning, as the patient stated, as wheals. The
general health, up to the time of the attack, had been excellent. In the
discussion, Curschmann remarked that, in the main, there seemed to be three
forms of gangrene of the skin — embolic, tropho-neurotic and cachectic. Occa-
illy, however, exceptions occurred, in which the disease could not be
placed in any of these groups.

The Etiology of So-called "Herpes Areolaris Mammae."

The condition described under this name, as Stumpf remarks {M&Rckener
med'i- '. ' nhritschrift, No. 25, 1888), does not partake so much of the

nature of herpes as of that of eczema. Both breasts are affected and the disease
involves the whole areolar region, being sharply defined at the border
Gelatin culture was made with portions of the crust, and gave, as a result,
a growth of fungus — a staphylococcus — morphologically the same as the
staphylococcus pyogenes aureus. The fungus was also found in the milk of
those affected. This latter fact, the writer considers, explains the rebellious-
ness of the disease, reinfection constantly taking place from the oozing milk.
The belief is stated, however, that the disease has its starting-point in the
areolar region, and subsequently the staphylococcus gains access to the milk
channels.

In the discussion that followed several weak points in the paper were
pointed out; it seemed improbable, if the cause was to be found in the
staphylococcus, that the disease would stop so abruptly at the margin of the
areolar region ; and improbable, also, that if the disease was kept up by
reinfection from the milk, for the upper part of the areolar region to be so
completely affected as the lower half.

POST-ECZEMATOUS FURUXCULOSIS.

The development of furuncles along with or following eczema is, as Inn a
states (J/ "/,• praitaoke Dermatohgie, No. 3, 1888), not uncommon,

and the longer the eczema has lasted and the less antiseptic remedies have
been employed, the greater the probability of furuncular lesions. To miti-
gate and to avoid this complication the incorporation of carbolic acid or
thymol in the ointments used for the eczema is advised. The addition of a
minute quantity of corrosive sublimate to oxide of zinc ointment, aided by
the administration of calcium sulphide, may be considered, however, the
in «t certain method to adopt in cases in which boil formation is likely to
o. car.

Trkatmkn r oi Eczema.

In simple eczema affecting the fingers and hands, Wetherell has had
{Lancet, June 2, 1888), in a number of instances, good results from the fol-
lowing simple plan of treatment : The fingers and parts affected are at night
individually enveloped with pieces of lint previously dipped in liquor carbonis

426 PROGRESS OF MEDICAL SCIENCE.

detergens (an alcoholic solution of coal-tar) and over this is bound gutta-
percha tissue. The smarting, which is felt when the dressing is first applied,
soon disappears. On removal of the lint in the morning the skin looks
sodden; a small quantity of lanolin is then rubbed in, in order that the parts
may be rendered soft and more pliable. The hands may be left exposed
during the day, but the effect is better if they are kept gloved. Every third
day the parts are washed with lanolin coal-tar soap. If a few small blisters
be present, they may be touched with carbolic acid. In the event of the pure
solution of coal-tar being too strong in cases in which there are consider-
able heat and redness, it may be diluted with from one to ten parts of water.
With suitable dietetic management and the use of internal remedies to meet
general indications, this method has, the author states, often proved of value.

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

VIS1TI.NO OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL.

The Treatment of the Vomiting of Pregnancy.

Hennig {Mi'nichener mtd. Wochensrhrift, No. 28, 1888) regards the milder
form of vomiting of pregnancy as due to a wound, inflammation or disloca-
tion of the uterus ; a distended bladder or rectum may also cause it. The
treatment is the removal of the cause.

The more severe form is sympathetic, and a neurosis. Nux vomica and
cocoa essence, or cocaine, are sometimes useful in these cases; dilatation of
the cervix he has rarely found successful. The induction of labor he con-
siclcrs the only efficient treatment for severe cases.

Sanger had seen one osm Ln which the vomiting was caused by carcinoma
of the stomach; in another, a laceration of the cervix provoked vomiting,
which ceased when the laceration was operated upon.

'r.tiblatf far Qytt&totogie, No. ~2\l 1888) regards the affection
as a reflex neurosis, and treated five cases by galvanism, the positive pole
being placed against the cervix, the negative between the eighth and twelfth
n vertebra-. From two and a half to five milliamperes were employed.
'■n to ten mini;
lie regard* the interruption of the current as the DQ0B1 potent cans.- of
irtion following eleetrieal treatment, and therefore takes especial paint
avoid the accident. His results were good.

Tl ItAI, l'i:i ..\\\< v, Willi KvillUMTION OF THE FcETAL SAC.

Doleris (Hull, tin* ./,• / ObdUHeak, No. 6, 1888) presented, al ■

recent meeting of the Obstetrical Society of Paris, the fimbriated extremity

OBSTETRICS. 427

of the left Fallopian tube, with a five months foetus, which he had removed,
with fatal result.

Rupture had just occurred when the operation was performed. The re-
moval of the sac left a large cavity in the pelvis;, the intestines being confined
by adhesions ; three large bleeding surfaces remained for treatment. The
patient died of shock.

< h ampioxxiere did not believe in extirpating the sac in these cases. He
had operated twice successfully by laparotomy, removal of the foetus and
draining the sac. It is in exceptionally simple cases that the sac can be ex-
tirpated.

Extrauterine Pregxaxcy simulatixg Ovarian Tumor.

Rosthorx ( Wiener med. I'n«e, Xo. 24, 1888) reports the case of a patient
who presented an ovoid tumor at the right cornu of the uterus, which was
thought to be an ovarian cyst. The tumor was removed; a portion of its
substance extended into the uterine tissue. The patient made a prompt
recovery. Dissection showed the tumor to be an extrauterine pregnancy.

Rosthorn divides these cases into tubal, ovarian and abdominal, and preg-
nancy in the uterine cornua. He recognizes the difficulties which attend
the diagnosis in these cases, and believes that in exceptional women the epi-
thelia of the abdominal cavity possess the property of developing a placenta
and nourishing an ovum ; this is known to occur in some animals.

The only method of treatment which offers a reasonable promise of cure he
believes to be laparotomy, no matter at what stags of pregnancy undertaken.

Axis-tractiox Forceps among German Obstetrician-.

An interesting discussion, showing the views of German obstetricians

rding the use of axis-traction forceps, was opened at the recent meeting

of the German Society for Gynecology (Miinchener med. Wochenschri/t, No. 25,

1888), by Bumm, of Wurzburg, who stated his satisfaction with Tarnier's

forct : -

He had found the weight of the instrument an advantage, and had rarely

used the compressing screw, but allowed the head to mould itself and rotate

freely as extraction proceeded. He applied them as he did ordinary forceps.

. er thought the broad handle of these forceps a great aid to easy

traction.

Duhrs-kx. with the Gusserow school of obstetricians, did not approve of
traction, but adopted Hofmeier's suggestion, to press the head into the
pelvis externally and apply short forceps.

Wixt kel preferred Breus' forceps, as lighter than Tarnier's.

[The Breus forceps is longer than the ordinary forceps, with more pro-
nounced pelvic curve, and has a light traction rod, detachable, smoothly fitted
at the posterior extremity of the cephalic curve ; it is commonly used in
Vienna for axis-traction. — Ed.]

The Treatmext of Abortion and Premature Birth.

Wixckei, (Munchener med. Woch July 10, 1888) concludes that

in the greater number of cases of abortion and premature labor the removal

428 PROGRESS OF MEDICAL SCIENCE.

of the ovum is best accomplished by nature : fever, profuse hemorrhage and
suppuration are the indications for prompt removal of the ovum. The best
method of removal is by the hand, expression and enucleation of the ovum,
after the uterus has been thoroughly disinfected by boric acid or creolin.

The curette should only be used when small portions of the membranes
remain adherent, and cannot be removed by the hand. Retained decidua
does not require the use of the curette. When suppuration occurs after the
removal of the greater portion of the ovum, the remaining fragments arc
most safely removed by repeated antiseptic intra-uterine injections.

The Bacterial Contents of the Lochia.

Orr (Archiv fur Qynakologie, Band 32, Heft 3, 1888) has examined the
contents of the uterus and vagina for bacteria, and found that in a healthy
puerpera the uterus and upper portion of the vagina contain no germs. He
concludes that the lochia of healthy women are innocuous. His method was
different from those of Doderlein and Winter, with the former of whom his
results agree.

The Spread of Puerperal Disease by Indirect Infection.

Fehling (Archiv filr Qynakologie, Band 32, Heft 3, 1888) regards direct
infection, since the hands and instruments of obstetricians are disinfected, as
infrequent. He believes that pathogenic germs often obtain access from
infected linen and furniture, and from the atmosphere. He cites a case in
his own experience in which erysipelas and puerperal sepsis followed the burst-
ing of a drain which infected the air of a ward. He considers primary infec-
tion to be that conveyed by direct contact of pathogenic germs from without.
Secondary infection is produced by the absorption of ptomaines produced by
germs which have entered the genital canal before or after labor.

Practical Disinfection of the Female Genitals.

Steffeck has made experiments upon various methods of disinfecting the
cervix and vagina, and concludes that, practically, thorough disinfection can-
not be obtained by one application of any agent, but by repeated use.

Irrigation of the vagina and cervix with a quart of bichloride of mercury

solution 1 to 3000, or carbolic acid 3 per cent., must be followed by irrigation

of the vagina at intervals of two hours with the same antiseptic to reduce the

Ability of auto-infection to a minimum.— Ckntralblait t'iir Qyn&tohgie, No.

M, 1888.

Acetic Acid a- \ \ \ $ tiseptic in Obstetkk >.

Engi'.i.m I >ihlittfiir Qyn&kohgie, No. 27, 1888) reports his results

in the use of acetic acid as an obstetrical antiseptic, as follows: It la
efficient as carbolic acid, less harmful, and penetrate! the ti-sucs more
deeply than bichloride <»f mercury or carbolic acid. Metallic instruments
may remain in a three per cent, solution fifteen minutes without injury. I:-
apon the hands is „.»t disagreeable. Bogelmano has employed it in three

OBSTETRICS. 429

per cent, solution for ordinary purposes, and five per cent, where a stronger
• was needed, in various obstetric cases with good results. A five per
rent, solution is slightly irritating.

The Etiology of Eclampsia and Albuminuria.

Santo3 (Archie far Gtjirik >' • • . Band 82, Heft 3) records fifty-three
I of eclampsia in the Buda-Pesth clinic, and concludes from his study of
the subject that albuminuria in pregnancy is the result of a reflex irritation
of the sympathetic and renal nerves caused by the increasing distention of
the uterus, and the irritation of the uterine nerves by this distention and
subsequent contraction. It is physiological in pregnancy, and a diagnostic
symptom of pregnancy. This conception accounts for the more frequent
occurrence of albuminuria in young women, in whom reflexes are most easily
excited. Any condition heightening the general reflexes favors albuminuria.

Santos regards eclampsia as an " acute peripheral epilepsy," whose genetic
zone is the uterus. Upon this basis he readily explains the action of narcotics,
and rare cases in which eclampsia occurs without albuminuria.

Pyaemia after Abortion, following Latent Infection with
Erysipelas.

Doderleix, at the German Society for Gynecology (Miinchener med. Wo-
chenschrijt, No. 25, 1888), reported a case of instrumental abortion for obsti-
nate hemorrhage, which was followed by fever and death.

Post-mortem examination revealed no gross lesions of the genitals, or the
lymphatics communicating with them. Bacteriological examination of the
contents of the uterus showed streptococci present ; they were also found in
one knee and middle finger and in pus at the base of the skull. Purulent
meningitis was the cause of death ; there was no peritonitis.

The patient had suffered from erysipelas a year previously, and the source
of infection in the present instance was the cervical lymphatics, which were
softened in the centre and contained streptococci; this latent infection had
been made active by abortion.

DSderlein stated that puerperal sepsis arose from infection of the uterine
cavity, or from specific infection of the lesions occurring at labor. Micrococci
introduced into the vulva by unclean coitus, masturbation or intestinal dis-
ease, may also infect the cavity of the uterus.

It is evident that we cannot discuss clearly the question of auto-infection
until we have disinfected the vulva and vagina in cases under observation.

The Influence of Bacteria upon the Digestion of Children.

Baginsky, in a paper before the Berlin Medical Society {Berliner klinische
Wochentckrift, No. 26, 1888), states that the bacterium of the lactic fermenta-
tion causes the production of acetic acid and acetone, as well as lactic acid.
This formation goes on without oxygen and is not hindered by the bile.
The neutral lactates are changed to butyric acid ; starch is not changed to

430 PROGRESS OF MEDICAL SCIENCE.

sugar, nor is casein or albumin decomposed. The gases formed when acetic
acid is produced are carbonic acid, hydrogen and methane.

He proposes to style this bacterium the acetic bacterium. He further found
that this bacterium is destroyed by acetic acid. In examining the stools of
children suffering from cholera iiifmitinn he isolated a bacterium which pro-
duced green stools (the germ of Hayem and Lesage) and also a bacterium
growing in white colonies. Both of these liquefy gelatine and both are inhib-
ited in their development by the acetic bacterium; this germ has the property
of preventing the growth of pathogenic germs in the intestine.

Baginsky considers that only the primary manifestations of cholera infinitum
are caused by bacteria, and that the secondary, severer phases result from the
extensive anatomical lesions in the intestine which have occurred. It is
evident that the treatment of a given case will depend upon the stage of the
disease. He found calomel, boric acid and resorcin prevent the growth of the
acetic bacteria; naphthaline and iodoform are inert. If the case is seen
early, when acetic fermentation is excessive, these remedies and the with-
drawal of milk are indicated. If pathogenic bacteria have accumulated in
the stomach or intestines, irrigation with antiseptic fluids is advised. Each
case. must be studied separately, and interference with the conservative pro-
cesses, as shown in the inhibitory action of certain bacteria, should only be
undertaken intelligently.

GYNECOLOGY.

UNDER THE CHARGE OF

HENRY C. COE, M.D., M.R.C.S.,

or NtW YOBK.

The Etiology of Vulvo-vaginitis in Children.

Pott (Archiv/iir Gyn&hologie, Bd. xxxii. Heft 3) has had ninety-six cases

of vulvo-vaginitis in children, more than one-half of whom were under five

years of age. He attributes it to direct specific infection, or some general

Mia, as syphilis or tuberculosis. Epidemics occurred from the infection

• nil children in the same family, through the medium of soiled linen,

as, etc. Cases of direct communication of the virus are rare, the writer

having observed only three. The entrance of <>.,■;, atO the

vagina was supposed to be a common source of vaginitis, but he found that

gonorrhoea was more often the true cause, in fact, he seldom failed to find

In -liscussing the above paper, Prociiuwmck stated that he had found the
enteea out of twenty-one caaee of yulvo-vaginitii In children. All
these patients suffered from severe urethritis.

SANGER said thai he had teen epidemics of vaginitis in families. Iii one
irl three and one-half years old developed intense peritonitis in

GYNECOLOGY. 431

-<quence of gonorrhoeal infection ; he believed that cases of pyosalpinx
and old localised peritonitis in young virgins might possibly be referred to
gonorrhoea contracted in childhood.

Melanotic Tumors of the Female Genitals.

Haeckei, {Arrh'n- /iir Qyn&tobgie, Bd. xxxii. Heft 3) reports a case of
melanotic growth, involving the external genitals, with secondary involve-
ment of the inguinal glands. The entire mass was extirpated and the patient
made a good recovery, but died five months later from metastases in the
abdominal viscera. Microscopically the growth was a melauo-sarcoma. Ac-
cording to the writer, only ten similar cases were recorded. Melanomata of
the internal genitals were still more rare, only two authentic cases of primary
disease of this character being on record. Such tumors never developed
primarily in the ovaries. When found in the vagina they were secondary to
disease of the external genitals. The majority of these pigment-tumors were
>mata. They gave rise to very few symptoms, pain, ulceration and hemor-
rhage being rare. They grew rapidly, soon involved the neighboring lymph-
atic glands and tended to undergo retrograde changes and to form metastases
in distant organs.

The diagnosis was made by their color, which was characteristic ; they might
rarely be confounded with ordinary sarcomata into which hemorrhages had
taken place.

The prognosis was absolutely unfavorable, most of the patients operated upon
dying from metastases in a few months ; only two cases had been reported
in which there was no recurrence after operation. Still, operative interference
was justifiable, in order to relieve pain and hemorrhage, even when it was im-
ble to remove all the disease. If the inguinal glands were affected, they
should be extirpated like the axillary glands in amputation of the carcino-
matous breast ; it was also desirable to remove all the masses of fat lying
between the tumor and the affected glands, in the hope of excising also the
diseased lymphatics which run in them.

Simple and Malignant Adenoma of the Uterus.

Ruge [Id.) describes clearly the microscopical differences between the two
forms of adenoma, in a paper read at the recent meeting of the German Gyne-
cological Society. The benign form is characterized by simple hypertrophy
and hyperplasia of the glands. The mucous is no longer sharply separated
from the muscular layer ; the interstitial tissue undergoes marked changes,
the cells increasing in size, so as to resemble those of the decidua, while their
nuclei become more numerous. Diffuse and circumscribed adenoma is simply
hyperplastic glandular endometritis. If small submucous fibrous polypi
undergo a similar change by a development of the glands in the mucous
membrane covering them, they must also be classed with adenomata, and
are to be regarded with some suspicion ; in fact, the uterus has often been extir-
pated on account of the uncontrollable hemorrhage to which they gave rise.

In malignant adenoma, in addition to the glandular hyperplasia, there are
changes in the entire uterine tissue, while metastases occur in other organs ;
in short, the condition is "clinicallv and anatomically true cancer." The

432 PROGRESS OY MEDICAL SCIENCE.

solid cell -processes invade the deeper parts to a greater extent than is common
in cancer. Extreme glandular hyperplasia is the characteristic mark of
miilignant adenoma. In general, the microscopical diagnosis of affections of
the endometrium present unusual difficulties.

Carcinoma Uteri Associated with Fibromyoma.

Lomlein {Centralblatt fur Oynilkolo'jie, July 29, 1888) presented, at a re-
cent meeting of the Berlin Obstetrical Society, a uterus removed per vagttum
on account of carcinoma of the body of the uterus. Aside from the ordinary
symptoms, the patient had complained of periodical attacks of pain, which
began at ten o'clock every morning, reached their maximum severity at noon
and disappeared at four o'clock in the afternoon. Simpson had originally
called attention to this phenomenon. The operation was so difficult that the
idea was entertained of resorting to supra-vaginal amputation. Lohlein
stated that it was now known that the association of carcinoma and fibroma
was not so rare as was formerly supposed. He had noted it in two out of
aeven cases.

Chloride of Zinc as an Escharotic in Carcinoma of the Cervix.

BHLBB8 (Id.), at the same meeting, reported several cases in which he had
used this agent in accordance with Van de Warker's suggestion. He had
made microscopical examinations of portions of the growth in each instance
in order to discover how deeply the caustic had penetrated. He had found
it somewhat unmanageable, since it often destroyed the healthy tissue more
than that which was diseased ; it had, in his opinion, no specific action.

In the discussion which followed Olshausen said that he disliked to apply
chloride of zinc to the uterine mucous membrane, because of its tendency to
form extensive cicatrices; he preferred tincture of iodine, which had the
property of checking hemorrhage and diminishing the secretion.

BftOfl stated that he had treated a large number of cases with the chloride
without having noticed resulting stenosis in a single instance.

Kiii.instadter's experience had been similar. He thought that the
chloride only destroyed the superficial layers of the mucous membrane, which
were reproduced without cicatrization, as after the use of the sharp curette.

L"iii.i:iN said that he had used this agent in certain inoperable cases of
carcinoma, and had not found, as Van de Warker had stated, that the pro-
longed contact <>(" a concentrated aqueous solution of the chloride with the
diseased tissues led to the formation of a line of demarcation between these
and the healthy portion of the cervix. He had observed no bad results alter
it* use; the wound granulated well, and in two instances firm cicatrices were
formed. It presented no advantages over other caustics.

Vowin. k i.i. >aid that he was accustomed to use chloride of zinc paste,
■ nling to the method practised in Czerny's clinic, viz.: Four parts of
chloride of zinc, three parts of flour and one part of oxide of zinc were made
into a paste with water, and this was enclosed in a piece of gauze, to which
waa attached a thread. Alter the diseased tissue had been thoroughly scraped
away with a sharp spoon, and the hemorrhage was checked, this tampon was
applied to the raw surface, the vagina being protected by a coating of vaseline.

GYNECOLOGY. 433

After remaini-; for about six hours (or for a less period if there was

danger of perforating the recto- or vesico- vaginal septum), the caustic was re-
moved and the vagina was tamponed with iodoform gauze. In this way the
action of the zinc was confined to the diseased tissue, hemorrhage did not
ir and the pain was not excessive.
Mai: iin's experience with Canquoin's paste had often been favorable, but
he had been led to abandon it because of cases in which severe hemorrhage
and perforation into the bladder, rectum and peritoneal cavity resulted from
its prolonged contact with the tissues.

Castration in Cases of Osteomalacia.

FXHZJKG (Archir fiir Gyniikoloyie, Bd. xxxii. Heft 3), from a study of
many cases of this affection and an analysis of the results of operative inter-
ference during labor, has arrived at the conclusion that removal of the
ovaries offers a cure. All the patients with osteomalacia who have recovered
after Porro's operation (twenty-four) were cured of the osseous affection, so
that they were able to walk about again and to work. The writer himself
has had four cures. This leads him to believe that the disease may be
arrested before the patient is allowed to become pregnant, by inducing the
premature menopause. He has performed oophorectomy with this object in
three cases; the first was entirely successful, in the second there was speedy
improvement, but after a few months the softening of the bones recurred,
although pain was absent ; in the third a sufficient length of time has not
elapsed since the operation to permit any positive statements with regard
to the result, although the patient was able to walk about soon after the
operation. In every case the ovaries were small, though not atrophied, while
there were large varicosities in the broad ligaments.

Intestinal Obstruction after Laparotomy.

Xieberding (Id.) reports three cases of obstruction, in one of which a loop
of intestine escaped through a hole in the mesentery and was nipped. In the
two others the gut became adherent to the wound ; the abdomen was reopened
in both instances, but the patients succumbed from peritonitis. He had
cleansed the peritoneal cavity with dry sublimated gauze, and wondered if
this had acted as an irritant.

Kaltenbach replied that he had frequently observed similar adhesions of
the gut, and attributed them to two causes, the use of too concentrated anti-
ic solutions, and imperfect disinfection of the peritoneal cavity after septic
material had entered it.

Pleurisy as a Complication of Ovarian Cyst.

Demons, at a meeting of the Paris Soei6t6 de Chirurgie (Annates de Qyn'e-
colo'/ir et (TObstttriqur, June, 1888), called attention to the frequent association
of pleurisy with ovarian cyst, which he had observed in nine out of fifty
cases. Pleuritic effusions may be unilateral or bilateral, and may even be
on the opposite side to the tumor. Although they usually accompany large
cysts, in some instances the latter may be small ; if a patient, having a

43i PROGRESS OF MEDICAL SCIENCE.

tumor not sufficiently large to interfere with respiration, is attacked with
dyspnoea, pleurisy should be suspected. It is important to note the incorrect-
ness of the general view that pleural exudations always indicate the presence
of malignant disease of the ovaries, with secondary affection of the pleura.
The adoption of this theory would lead surgeons to refrain from operating
upon patients with simple ovarian tumors. The effusion may be due to an
obstruction of the lymphatics of the pleura, following a similar obstruction of
those of the abdomen from the pressure of the tumor.

In the discussion which followed, Terrier stated that he had observed the
association of pleurisy and ovarian cyst, and generally attributed the former
to secondary cancerous disease, even when the cyst was apparently non-malig-
nant; nevertheless, operative interference in these cases was not contraindi-
cated, because, if the pleuritic effusion was due simply to pressure it would
disappear after removal of the cyst, but if it was of cancerous origin the
patient had nothing to lose from the operation. He always punctured the
pleural cavity before performing laparotomy, when there was extreme dyspnoea,
and had never regretted having done so.

Bouilly believed that the complication was rare, having noted it only
twice in twenty- five or thirty cases. There was no reason why effusions should
not accompany simple, as well as malignant cysts, although the prognosis was
different in the two cases.

Championniere thought that pleural effusion, or, more properly, hydro-
thorax, was most frequently associated with proliferous cysts, with or without
resulting ascites; the prognosis was always grave. An examination of the
urine would show that the daily amount, as well as the quantity of urea, was
considerably diminished.

Terrillon had discovered a pleuritic effusion in only three out of one
hundred and twenty cases of ovarian cyst, although he always examined the
thorax carefully. He recognized two forms of effusion, the simple variety :ic-
companying benignant tumors, in which absorption readily occurred, and that
associated with cancerous or proliferous cysts, in which there was probably
secondary disease of the pleura.

Vernetjil said that any abdominal tumor, whether connected with one of
the pelvic or abdominal viscera, might be complicated with pleural effusions.
Potato had shown that a similar effusion might result from congestion of the
ovaries and jxri-ovarian tissues, from reflex irritation and hyperemia; it
might be on the same side as the affected ovary, or on the opposite side.

PUBLIC HEALTH.

DKB mi: OHAJtGl OF

Siiiki.i.y P. IfUlPHY,

LBCTCMKB OM NMH HEALTH AM. IMiMKNK, ST. MART-* HOM-ITAI, I

VaoCIWATTOS Siati-tics in Germany for 1883.
Then were in Germany, in tin- year 1883. 1,867,569 children who had
attained the age when vaccination was obligatory, but of these, 189,611, or

PUBLIC HEALTH. 435

ld.21 per cent, remained unvaccinated, 99,496 of them being, as stated by
certificate! from medical men, unfit for vaccination. Of those who were vac-
cinated, in 1,190,163 cases, or 87.03 per cent., the result was successful, In
280 it was unsuccessful, and of 5517 nothing is known, as they did not
return for examination. With regard to the localities in which the greatest
proportion of children were vaccinated, Swabia may be considered to rank
highest with 97.17 per cent., and Bremen the lowest with only 70.63 per cent.
< )t* the total number in Germany, 108,182 were vaccinated with humanized
lymph and 145,526 with animal lymph; in addition to these were 12,989
children, with whom it is not stated what kind of lymph was used. The total
number of children who were revaccinated was 930,732, leaving unprotected
by revaceination 38,086 children ; of those who were revaccinated, in 820,336
cases the vaccination was successful ; the best results, viz., 97.33 per cent.,
were, obtained in Schaumburg-Lippe and in Lower Bavaria, where the results
were 96.14 per cent. The majority of those children who were unsuccessfully
vaccinated were revaccinated in the following year, and thus the number
remaining not revaccinated is very small. There were 831,072 revacciuations
performed with humanized lymph, and 96,404 with animal lymph.

Extracts from reports of the various provinces give information concerning
the period of the year when vaccinations are performed, the kind of place
used for the purpose, the method of the operation, and the number of vesicles
required by the different governments. Generally, from May to September
most of the vaccinations take place, and but few towns have special accom-
modation, public buildings, town halls, schools, gymnasia, etc., being used as
vaccination stations. In some provinces it was considered desirable that
vaccinations should be postponed, owing to the prevalence of one kind of
epidemic disease or another; in other provinces no postponement was made.
Specially appointed medical men perform vaccination in most of the prov-
inces, the methods employed in the operation varying in almost every prov-
ince. To obtain lymph for the general vaccinations persons are vaccinated
before the customary period with lymph obtained from government institu-
tions, from some of which only humanized, from others animal lymph is sent,
sometimes mixed with glycerin and sometimes as a dried powder; where
animal lymph was much used, as in Hesse and Baden, the insertion success
was from 96 to 100 per cent., and there a paste of lymph and glycerin was
used.

In Wurtemberg there were 30 cases of original cowpox, from 10 of which
inoculations in man were successfully performed, and from one case an
animal was inoculated. The opposition to vaccination had not increased in
the course of the year, and occurred in many cases more from neglect and
ignorance than from any intentional desire to prevent the children being
vaccinated. As regards the cases of illness and death occurring after vacci-
nation, there were some of the former from inflammation and glandular
enlargement, but none was fatal; erysipelas caused 11 deaths, blood-
poisoning 2, in Prussia and in Posen ; and some instances of skin eruptions
are mentioned, but not one case was observed of syphilis having been
transmitted by vaccination. One child appears to have thrust its head
against a lancet when already charged, a vesicle forming on the place of the

436 PROGRESS OF MEDICAL SCIENCE.

wound ; and a girl of twelve years old, when revaccinated, fainted. — Arbeiten
aits dem Kaixerlichcn GcsuiidhrUsaiiite, Band II., Hefte 1 and 2.

The Upper Silesian Zinc Industry, and its Influence on the
Health of the Workers.

The zinc smelters in Silesia are mostly taken from amongst the Sclavs, who,
according to Dr. Tracinski, are of middle height, with ill-developed
physique and of phlegmatic temperament, almost approaching indolence.
Their mode of living, until the last few years, was most miserable; they sub-
sisted on vegetables and bread, living in huts with all kinds of animal!;, from
early life compelled to assist their parents in the hardest labor, exposed to
privations of all sorts and mostly devoted to alcoholic excess. In this way
they became a prey to the various diseases consequent on their occupation,
and rarely attained to old age ; but of late years great progress has been
made with regard to their dwelling and food arrangements; they chiefly in-
habit two-storied houses, which they obtain at moderate cost, or they are
permitted to buy plots of land on which they build their own houses. The
wages have increased, so that they are enabled to live on meat and bread
instead of vegetables, and they clothe themselves more warmly in winter
than formerly, thus guarding themselves against chills. In some factories,
arrangements are made for workmen's baths and in most of the smelting villages
there is one sick club, if not more, which secures for the workman, if he pays
regularly, free medical attendance and medicine, and, if necessary, removal
to a hospital, besides an allowance during his illness. If alcohol could be
forbidden in zinc works as in mines, there would soon be a still greater im-
provement in the health of the workmen; but the nature of their employ-
ment brings in course of years fatal diseases to all who are engaged in
smelting works. The dust which is inhaled and the irritation of the sul-
phurous gas induce obstinate catarrh of the air-passages which leads finally
to emphysema of the lungs. The disturbance of the circulation causes a
failure in the oxidation of the blood, and, besides, the dust and metallic sub-
stances such SB lead, sulphur, cadmium and sometimes arsenic and zinc,
which arc swallowed, cause diseases of the mucous membrane, disturb the
ition and produce catarrh of the stomach. By degrees, the whole con-
stitution begins to suffer, the muscles dwindle away, the skin loses its color
and becomes ashen and pallid, the eyes are sunken, the body is bent, the walk
slow and dragging, either in consequence of repeated attacks of rheumatism, or
that through disease of the muscles caused by lead. Thus it may be reckoned
the age at which a zinc smelter ceases to be capable of work is forty-five years.

Efforts >houhl he directed toward procuring for workmen good drinking
water, opportunity for washing and bathing, and, when possible, the Intro-
duction of Siemens stoves and suitable receivers, so as to shut off the smoke
from the smelting houses.— A .,/»./, IV- rfrfjit/irw/iriff j'i'tr offentliiir Qttund-

Band SO, licit 1, 11

I.I .Al'-l'oIsuMNt;.

In lss7t upward of ■ hundred persons near Roanne, in France,
attacked with colic of gr. >me suffered from lassitude and general

PUBLIC HEALTH. 437

pains, others from vomiting. It was later discovered that some had well-
marked blue lines on their gums, and the water-supply wa- examined, hut as
it was derived from several sources, it was eliminated from suspicion. Other
articles of (bod were examined, and especially the flour, when it was ascer-
tains! that about sixty people, who were seriously ill, had partaken of flour
from a particular mill. A sample of this rye flour was analyzed, and lead
was ascertained to be present In it, though to what extent could not be esti-
mated. [( was then discovered that the grain at the mill was transported to
the millstones by means of an elevator of buckets which were found to con-
if tin-plate containing a good deal of lead. The rye flour which passed
through these buckets contained not less than five ounces of the metal which,
had been rubbed off into the grain, and those persons who had eaten rye
bread exclusively suffered most severely, while those who used wheaten
flour,, obtained from another elevator, were not attacked at all. In certain
parts, utso, a deposit of sulphide of lead was found, owing, probably, to the
cracks in the grindstones having been filled with sulphur and which had been
brought in contact with the buckets.

Another case of lead poisoning was in March brought before the Paris
Societe" de Chirurgie by M. Duguet. A woman, thirty-eight years old, was
employed in a factory to gum small bands of paper on to colored cardboard
boxes. In order to pick up the bands she was obliged each time to wet her
fingers with her tongue and afterward to wet one side of the band that was
colored gray, the other side being colored orange, so as to gum the band on
to the box. She frequently gummed as many as five thousand in one day;
she stated that her companions, when doing the same work, became pale and
thin and suffered from colic, while those who gummed the blue bands did
not suffer at all. The bands of paper were analyzed and each was found to
contain one-fifth of a grain of lead in its metallic state. — Sanitary Rerun I,
January and March, 1888, pages 337 and 430.

Outbreak of Febrile Disease.

Dr. Russell, Medical Officer of Health for Glasgow, has published the
history and circumstances of a peculiar outbreak of febrile disease during
March of this year, in St. Mary's Roman Catholic Industrial School in Glas-
gow. Children were taken ill with headache, in a few hours became uncon-
scious or maniacal and died; others, after a few hours' illness, suffered from
pneumonia and herpes, eventually recovering, while others, again, passed
through a pyrexial attack of an ill-defined nature. The school consisted of
207 boys and 194 girls; 66 of the former and 2 of the latter were attacked,
the cases being 4 which ended fatally, 31 with severe symptoms recovering
and 33 mild cases. In two bodies examined, the most important appearance
was that of the intestines, which in each case showed considerable enlarge-
ment of solitary follicles and Peyer's patches, together with enlargement of
the mesenteric glands.

The food supplies for the boys and girls were received from a common
kitchen and could be eliminated from suspicion. There was, however, an
amount of intercommunication between the two schools, which in the case of
an infectious disease, such as typhus, scarlet fever or smallpox, appearing in

438 PROGRESS OF MEDICAL SCIENCE.

one institution, soon gives practical demonstration of reality. The two girls
attacked were both employed in the kitchen, one of them was a sister of one
of the boys attacked, and was visited by Iter mother immediately after she
had been with her son in the boys' sick room. As regards the other girl
there was no element suggestive of infection excepting employment in the
kitchen.

Dr. Russell gives the following summary of his investigation : " The schools
are situated in a densely populated district; they are enclosed by surrounding
tenements and other large buildings, together with a graveyard which was in
1875 described as "greatly overcrowded with bodies and kept in a state of
rank disorder," and in which have since been interred 577 bodies; the free
space attached to the schools, and available for exercise, is small; the internal
air-space in both is deficient; the inmates are children between five and fifteen
years of age, who are weak in constitution, tainted with a proclivity to scrofu-
lous diseases, and generally of low vitality; the death-rate is higher than that
of other industrial schools which have received the same class of Glasgow
children ; the proportion of total deaths from pulmonary diseases is enormous,
contagious or infectious disease is nearly always present, and there have been
repeated epidemics of typus fever, a certain indication of overcrowding."

The overcrowding is much greater in the boys' school than in the girls', the
internal arrangements are more defective, the general sanitary condition of
the building is inferior, the general mortality and especially that from pul-
monary diseases is considerably higher. Dr. Russell states that he considers
the outbreak in March to have been " a febrile disease tending to implication
of the lungs and especially to pneumonia; it suggests a specific poison from
family resemblance, in explosive character, local limitation, and elinieal
features, to other well-known typical diseases of the epidemic and in feet ions
class. No specific microorganism was discovered in this outbreak.

The rapid fatality of the fatal cases shows that this poison was the cause of
the disease, though in cases in which life was not at once extinguished it
tended to expend itself upon the organs of respiration. The local disease
was the result of a constitutional infection which was capable of killing with-
out the local disease. The post-mortem appearances pointed to a specific
poison allied to that of enteric fever. Such as they were, they were distinctly
lesions of the mesenteric gland and of the glandular system of the small in-
testine. The experience of the Fever Hospital (Glasgow) is strongly sugges-
tive of a causal affinity between certain forms of pneumonia and enteric fever.
— (History of a Peculiar Outbreak of Febrile Disease. By J. B. lit ssi:u..
M.H.. Medical Officer of Health for Glasgow.)

Note to Contributors — All communication- intended for insertion in the Original
Department of this Journal are only received with the distinct understanding that tinw-
are contributed ex< kale Journal for publication. Gentlemen favoring as wit*
inmunications are considered to be bound in honor to a strict observance of tail
understanding.

Liberal compensation is made for articles used. Extra copies, in pamphlet form. will.
if desired, bo furnished to authors in lieu of compensation, provided the request for them
be written on the manuscript.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES.

NOVEMBER, 1888.

THE TREATMENT OF VALVULAR DISEASES OF THE HEART.1
By J. M. Da Costa, M.D., LL.D.,

FBOrcssos or the principles and practice or medicine in the jErrtrsoN medical

COLLEGE, PHILADELPHIA.

This paper is intended to deal with matters connected purely with
the treatment of valvular diseases of the heart. In it I desire to record
some opinions formed by experience; to trace lines of procedure ; to see
in how far new therapeutic agents have added to our resources ; and to
try to make out in what direction the hand of progress points.

rinrt'i famous quotation as a motto for his classical treatise on
diseases of the heart, Hceret laterl lethalis arundo, represents the thought
for a long time prevailing, and still largely adhered to, certainly as
regards valvular affections, that nothing can be done for such grave
conditions : the fatal arrow must stay implanted until death loosens it.
Side by side with this opinion has been, of late years, the doctrine
strongly urged that treatment should be based on the particular mis-
chief at valves and valve openings and its supposed necessary conse-
quences on the walls, and rules are laid down for the use or avoidance
of remedies in accordance with these preconceived ideas, and with the
special name the valvular disease bears. Thus, in mitral regurgitation.
as well as, and even more markedly, in mitral narrowing, digitalis is
to be employed to increase the propelling power of the heart ; in aortic
regurgitation, with its large left ventricle, this drug is to be avoided —
may be even daugerous; and, as the resulting hypertrophy is mostly

1 Road before the Association of American Physician*, September 19, 1888.
tol. 96, no. 5.— November, 1888.

440 DA COSTA, VALVULAR DISEASES OF THE HEART.

sufficient, digitalis is of little or no use in aortic narrowing. In tricuspid
regurgitation we are taught by some never to omit its use, whatever else
we do ; by others, that as there is no compensatory muscular change, it
is impossible that it can be of any service.

Now, from these doctrines and the suppositions on which they are
based, I dissent. I think they only embody half truths, which, rigidly
applied, will lead to wrong practice. I believe they ought to be taken
simply as very general statements concerning the particular tendency of
each valve disease, but not be the guide in an individual case without
an accurate study of the special features of that case. I hold, then, that
the precise valve affected is not, with our present resources, the keynote
to the treatment of valvular heart disease. Much more important is it
to regard the state of the muscular fibre ; the size of the cavities ; the con-
dition of the arteries, veins, and capillary system ; the secondary results
of the cardiac lesion ; the control of the nervous system. Important,
too, it is to bear in mind the cause of the malady. Holding these views
and largely based on them, I advance these propositions for the manage-
ment of cases of valvular disease of the heart. We are to take as indi-
cations :

1. The state of the heart-muscle and of the cavities.

2. The rhythm of the heart-action.

3. The condition of the arteries and veins and of the capillary system.

4. The probable length of existence of the malady, and its likely
cause.

5. The general health.

6. The secondary results of the cardiac affection.

It is on these considerations that the treatment of valvular affections
turns, and the first of them is, from a practical point of view, the most
important. It influences action in diverse ways. Thus, if we have
a case with heart muscle which has increased in size simply to the
extent necessary to overcome the difficulty made by the valvular im-
perfection ; in which the cavities are but little stretched ; in which a
stronger impulse is not associated with marked apex displacement or with
greatly increased transverse percussion dulness; in which the arteries
do not throb inordinately, nor the veins are turgid, nor the surface
mottled and the capillary circulation sluggish; in which there is do
dropsy, no respiratory embarrassment ; in which the general health is
good, and exercise does not produce inordinate distress, — we know that
compensation has fairly followed injury, that heart muscle and cavities
are in, for that case, healthy condition, and should endeavor to keep
them so by simply regulating the patient's life and habits. No matter
by what name the valvular disease is labelled, there ought to be no
interference with it by drugs, certainly not be remedies which act on the
heart.

DA COSTA, VALVULAR DISEASES OF THE HEART. 441

But the same patient may show excessive cardiac growth and force,
and be greatly benefited by cardiac sedatives; or later he presents a
halting beat of the heart, the cardiac dulness has increased, so has the
impulse in extent, but not in force; there is oedematous swelling around
the ankles ; the veins are more prominent ; lungs and liver are engorged ;
small vessels are visible in the skin, and are tardily emptied by pressure ;
— the stretching, faltering heart calls for support, and is rallied, made
regular, and kept for a long time performing its functions admirably,
by the persistent employment of moderate doses of digitalis. Yet this is
the same patient ; all the while the disease bears the same name. But
his treatment has been followed by such striking results because the
state of the heart muscles and of the cavity has been fully recognized,
and been made the basis of remedial interference.

Persons thus supported in their circulation may be kept alive for
years and capable of leading useful lives. But this is not the main
point I wish to bring out. It is chiefly that the same valvular dis-
ease will at different times, according to the varying state of heart mus-
cle and cavity, require very varying treatment. In truth, I have had
cases come under my observation in which the active state of the circu-
lation, the marked hypertrophy, the cardiac uneasiness were always
greatly relieved by aconite, and so much aggravated by digitalis, which
produced a sense of cerebral uneasiness and weight, that the patient
had the greatest dread of this drug, even for temporary purposes; yet
I have known such cases in time, when the heart began to weaken, owe,
for years, their life to the steady use of digitalis.

The class of cases just alluded to, chronic in their course with slowly
deteriorating compensation, are, usually, those in which small doses of
digitalis act so favorably. The quantity required is, indeed, rarely more
than ten drops of the tincture twice daily, kept up until the effect on
the heart and pulse becomes perceptible — which may be in a week or in
several, — and then suspended, to be resumed according to circumstances.
Nay, I have found a single dose of ten drops, repeated once in twenty-
four hours, preferably at bedtime, show the same happy results. Some
patients do better with five drop doses, every fourth or sixth hour. But
the rather larger dose, at longer intervals, is usually the less disturbing
plan. Should the digestive organs become deranged, I use digitalis by
suppository : from two to four minims of the fluid extract incorporated
in cocoa butter are efficient.

Digitalis acts in the cases under consideration chiefly as what is called
a heart tonic ; it makes the contractions of the cardiac muscle stronger
and slower, it produces a fuller flow in the finer vessels. It answers, as
already stated, in small or in very moderate doses. It is required in
much larger amounts in those instances of valvular disease, compara-
tively rare, in which there is almost from the first dilatation and all the

442 DA COSTA, VALVULAR DISEASES OF THE HEART.

excessive feebleness of circulation this brings with it ; or in which, late
in the history of the valve affection, the dilatation has outstripped the
hypertrophy. Under both these circumstances of cardiac weakness,
digitalis may be alternated with strychnia and supplemented by alcohol.
There is yet another cardiac condition encountered in valvular disease,
in which digitalis is the principal remedy, and in still larger doses. It
is where the compensatory hypertrophy is gradually lessening in pro-
portion to the valvular defect; where the venous system is becoming
gorged, the breathing much oppressed, the internal organs congested ;
where the feet are beginning to swell, the pulse is rapid and compres-
sible, and the heart often fitfully excited ; it is when the symptoms
become rather suddenly aggravated, and a sense of weight and distress
in the cardiac region suggests that the organ does not fully empty itself,
that larger doses of digitalis will show a wonderful influence. Fifteen
minims of the tincture every second or third hour will not only cause
the struggling organ to contract powerfully and help the general circu-
lation, but will diminish the choked condition of the cavities, notwith-
standing that up to a certain point digitalis prolongs the diastole. The
action of the drug is helped by ammonia, by brandy ; but while given in
hese large doses the patient must be kept at rest. The mischief once
checked, smaller doses will again show their good effects. We may
meet with the condition under discussion in any case of valvular dis-
ease ; undoubtedly most often in mitral complaints, but also in advanced
stages of aortic regurgitation ; and, if in the latter affection, we need
not be deterred, on theoretical grounds, from withholding the treatment
indicated.

In the remarks just made it has been assumed that we are dealing with
hearts in which the muscular fibre, however increased, is, on the whole,
healthy ; in other words, not in a state of degeneration. But supposing
that it be ; supposing that there be a granular, or a fatty, or a waxy, or a
fibroid change. Is the treatment to be altered? I do not think that it
can be materially modified except in the rather steadier use of stimulus ;
yet we will not obtain the same result from digitalis or kindred agents,
and arsenic or strychnia is always worthy of trial. These are difficult
cases to treat, and difficult cases to recognize. The age; the history,
which shows a likelihood of fatty or other degeneration: the taped of
the patient; and the very fact that the heart muscle does not seem t
spond to cardiac tonics, give us a clew to the true character of the alii c-
tion. Neither the sphygmograph nor the cardiograph helpi us much
in the recognition*

\\V have been considering heart complaints, and they are the most
common, in which looner or later the compensation is defective, and the
heart has to be sustained. But th.ro arc eases, already alluded to. in

which this never happens, in which no interference is required, in which

I'A COSTA, VALVULAR DISEASES OF THE HEART. 443

the patient, if patient he can be called, has a heart quite sufficient for
tin ordinary purposes of* life. It gives him no uneasiness, and, even if
aware of his cardiac malady, its existence ceases to trouble him. These
are especially cases of aortic disease, narrowing or regurgitation, par-
ticularly the former, with marked, but not excessive hypertrophy.
Secondary results of the cardiac affection are not seen; though, as is
fully recognized, there is greater tendency to sudden death, and violent
exertion must be avoided. Yet I have known persons having these
aortic maladies distinguished in pursuits with constant strain ; one, an
officer of many campaigns ; the other, a most laborious physician ; the
third, the captain of an athletic team at a college proud of its athletic
eminence ; and not one is aware of being the worse for exertion, suf-
fering neither pain nor shortness of breath. Two have lived over
tw.nty years since I have been cognizant of their malady ; they do
nothing to counteract its effect, except leading a very temperate life.

Yet another class of cases presents excessive muscular growth, and
cavities that have but moderately increased. This state is more often
met with in aortic affections, particularly regurgitation ; but it mayalso
happen in mitral regurgitation, with or without coexisting aortic disease.
The impulse is extended, forcible, and forcible out of proportion to the
cardiac percussion dulness ; there is often throbbing of the vessels of
the neck, dull headache, tension in the pulse, and a fee iug of constric-
tion in the chest. Aconite is preeminently the remedy ; it diminishes
the blood pressure in the arterial system and gives great relief. I usually
employ two drops of the tincture, every fourth or sixth hour, for the
first few days of the treatment, and then only twice a day ; or give one
drop every third hour until an effect on the force of impulse and pulse
is produced, and keep up this effect with a drop dose, two or three times
a day. for several weeks, intermitting the treatment, and resuming it
from time to time. Veratrum viride hassimilar applicability ; it is, how-
ever, more apt to nauseate. But I have often had the happiest results
from a combination of one-drop doses of aconite tincture with three of
tincture of veratrum viride, and seven of tincture of ginger. It is an
admirable sedative, and does not sicken.

Summing up, then, the treatment of valvular affections of the heart
as they present themselves ordinarily, and basing it chiefly on the condi-
tion of the cardiac muscle and of the cavities, we find practically three
groups:

Cases in which no sj>ecial treatment is required.

' -es in which excessive growth and strong action call for aconite or
veratrum viride.

Cases in which, either early or late, and with or without increased
mncle, the heart falters and needs support, and for winch digitalis, IH
differently according to varying indications, is the principal remedy.

444: DA COSTA, VALVULAR DISEASES OF THE HEART.

This line of treatment is held to independently of the exact valve
affection. It requires tact and experience to adjust it to the individual
case. But when adjusted, the results are excellent.

I turn now to the other points laid down at the beginning of this
paper, which are to guide our therapeutics. They will not long detain
us; for they are of far less importance than the one just considered.
The rhythm of the heart, its regularity or irregularity, has, indeed, been
already alluded to in connection with the state of the cardiac muscle
and cavities. Still there are cases, especially of mitral narrowing, in
which the extreme irregularity presents a striking feature, and in which
the question naturally arises, whether we cannot do something special to
remedy so threatening a condition. They are mostly cases with imper-
fect or weakening compensation, and, therefore, to be benefited by digi-
talis and remedies of that class. Yet, as an adjunct to this treatment,
belladonna may be advantageously employed, and pushed to its consti-
tutional effect. From belladonna alone I have not seen any marked
results as a cardiac tonic ; but, without depending entirely on it, I know
it to* be valuable for the relief of irregular action.

The condition of the arteries and veins and of the capillary system
furnishes an indication for treatment which is apt to be overlooked.
Attention is paid to the veins and to their turgescence in instances of
dilated right heart and cardiac dropsy. But there is the equally im-
portant state of the arteries, of the arterioles and capillaries, and the
appearance of the skin and the network of fine vessels in it, by which
we can judge of the more minute circulation. Now, we must remember
that the very remedy we use most in cardiac disease, digitalis, contracts
the arteries and arterioles, and the indications are often to get with in-
creased cardiac power a free flow iu the vessels without resistance from
them. No remedy does this ; and a certain remedy of the kind is greatly
needed. It is claimed that strophanthus has this valuable property, that
it is a cardiac tonic which does not also contract the bloodvessels ; but this
is not proved — indeed, recent researches, such as those of Bahadhurji,1
suggest the contrary. Still, the evidence is in favor of strophanthus c..u-
tracing the vessels to a much less degree than digitalis. Nitroglycerine
and the nitrites produce rapid and great dilatation of the vessels, but
have, I think, very little effect on the muscular power of the heart
Belladonna and atropiain decided doses have somewhat the same action

1 Brtttth Medical Joiiriiiil, Sept. 1887 ; also comments on hit* rosearrlirs by li 0. Wood (Thwpiw
ties, seventh edition, 1888.) Lauder BmBtOB ( Pharmacology, third edition, 1888) speaks of ttropkoa-
thus as not producing "so marked a contraction" of arterioles aa digitalis. Purdy's observations
.igo Med. Journ. and Exam., March, 1KS7) lead him to tli.- conclusion that stiophanthus acts only
In large doses upon the vessels. Eornor and A. I.i'.w (Wlon. nod.. WoohOMOhr, CO :■••'• - i", 1887)
give many pulse-tracings and arrive at much the aaine results as those originally pabtlobod bj Kraser.
They found strophnuthu* to cause a more en. i and loafOZ diastole, 0. Ithout pnxhtata|

traction of vessels. The whole subject PBldl Author InTtffHgnttotl.

DA COSTA, VALVULAR DISEASES OF THE HEART. 445

as nitroglycerine, less on the vessels, rather more on the heart. Why
can we not learn to combine nitroglycerine or atropia with digitalis in
right proportions, and obtain, where we so wish it, full cardiac power
without resisting vessels?

There is, I am certain, a rich field here for accurate research. While
waiting for an agent which by itself has the needed qualities, we can use
the remedies we possess to modify each other ; and in the class of cases
with sluggish capillary circulation we may also make use of gentle
massage.

The probable length of existence of the malady and its likely cause
must be taken into account in treatment ; the former, because it gives
us an idea how actively the process of compensatory hypertrophy is
going on, and whether it had better be stimulated or checked. Besides,
it bears on the point whether the original malady is so far off that it is
still worth while treating. In this respect, then, the consideration of the
duration and of the cause of the valvular lesion merges.

Now, let us consider this question of cause. It is needless to repeat
all the possible causes of valvular mischief; the most prominent cer-
tainly is rheumatism, next come the degenerative changes, as of advanc-
ing years, of Bright's disease. When rheumatic, can we treat it
specially? My experience says distinctly not. We possess no remedies
to influence the results of the rheumatic endocarditis, when the acute
• is fairly over. Indeed, if it be three months after the attack, I
believe the attempt useless. Before this, it may be worth while to try
a course of iodides, of blisters, of rest. It will generally fail ; but I
have twice seen loud murmurs, left after rheumatism, thus disappear,
and, I believe, the valve restored. When the attack dates some time
back, no good results come from attempts at absorption. I have several
times watched the effects of long-continued, faithfully carried out trials.
One, in the person of a middle-aged physician who was determined to
get rid of a rheumatic mitral disease with a marked systolic apex mur-
mur, and no signs of pulmonary congestion. He kept himself saturated
with iodides for a year, only stopping for short intervals, when sickened
by the drug. At the end of a year the murmur was just as distinct as
before, and his general health certainly not so good ; the extent of
hypertrophy appeared unchanged. I watched a similar case for eleven
months; the result was the same. Yet it is well in instances which
have clearly a rheumatic origin, to guard against the possibility of the
recurrence of the rheumatism, since this may lead to an aggravation
of the valve mischief; it is well at the first sign of a rheumatic out-
break to insist on rest and to administer freely alkalies, or the salicy-
lates. At all times, too, ought the food, the clothing, and life gener-
ally, to be regulated as it would be in any one liable to rheumatism.
The same line of thought, though not with exactly the same agents, will

446 DA COSTA, VALVULAR DISEASES OF THE HEART.

indicate to us how to manage the heart disease of the gouty, with the
occasional appearance of large quantities of lithic acid in the urine.

With reference to atheromatous disease, with its pulse so often of
higher tension than the cardiac condition would indicate, we can, with
our present knowledge, do nothing for the gradual decay which is going
on. Acids have been suggested, but acids will not answer. Doubtless,
future therapeutics will include solvents and other means to influence
degenerative states, and they will be used in cardiac affections. Viewed
now, we can only say that this kind of cases requires a more constant
though varied, cardiac support than the recognizable organic mischief
calls for.

There is, however, a form of valvular affection of the heart in which
we can treat the malady according to its cause with the happiest re-
sults; it is the form which I have called functional valvular disorder.
Since the publication of my paper on the subject,1 I have had many
more cases of it, and have learned to remedy the perverted valve action
and its consequences in a number of instances which at first appeared
to be incurable organic valvular disease. This was accomplished by
rest, followed by graduated exercise, by careful diet, and by the per-
sistent use of small doses of digitalis, or, in some later cases, of adoni.
dine. The cases were chiefly mitral regurgitant affections ; two of them
distinctly followed heart strain from excessive rowing. They were not
in any sense anaemic. In two in which the treatment was concluded
within the last year, and one of which had considerable pulmonary en-
gorgement, the valve has so completely returned to its normal action
that no murmur could be detected by experts who saw them subse-
quently.

It seems almost needless to speak of attention to the general health,
as an indication for treatment, were it not that some important consid-
erations are involved. In the first place, it is evident that the better state
we keep the blood in, the better the heart muscle will be nourished, the
less likely to undergo degeneration. This is, perhaps, the reason why
iron is so often thought of as a routine practice in valvular atfeetions.
Yet it is, as a rule, not a good remedy; it constipates, produces head-
ache, a full feeling about the heart, and is badly digested. It ought
only to be given in cases clearly amende, or after recovery from an acute
malady. Food is generally much more important than iron. It should
be nutritious, easily assimilated, hut never taken in large quantities at a
time. Strong broths, fish, eggs, meats, poultry and name, and Rich
green vegetables and fruit as are readily digested must form the basis of
the food supply ; and those who like milk, or have no distaste for digested
milk, can take either in moderate amounts to advantage. There is no

1 Akmicax Joumai. or th« Medical Scir.xrKu, July, 1869.

;

DA COSTA, VALVULAR DISEASES OF THE HEART. 447

objection to the use of coffee and tea if not excessive, and small quantities
of alcoholic drinks are rather beneficial than otherwise in inadequate or
filtering compensation. Except for gouty persons, we may hold to
uom, that it is quite right to allow alcohol in cases to which we
think digitalis applicable. The light wines are well borne and apt to
be of service. Champagne is bad for most patients. I have known even
a single glass produce violent palpitation, cardiac distress, and oppres-
sion. The dress should be loose-fitting and warm; and, owing to the
readiness with which laryngeal and bronchial catarrhs arise, exposure
to cold and damp should be avoided.

With reference to exercise, it is difficult to lay down rules. Of course,
all violent exercise, like all sudden efforts, is to be avoided : and, in the
cases with rapid circulation, I believe in considerable repose. But
where the heart is not acting too violently, nor too rapidly, there is no
doubt that regulated muscular exercise, especially on foot, is of use, as
it sustains the nutrition of the organ. It must be kept within the limits
of not producing shortness of breath, and ought not to be undertaken
in the face of a strong wind. Of the hill-climbing and mountain-
climbing plan of treatment, recently advocated by Oertel, I have had
no experience. What I have seen of the difficulty people with valvular
heart affections have in living in mountainous regions, as in Colorado,
does not incline me favorably to the plan. Keeping the nervous
system as quiet as possible and being cheerful, are undoubtedly great
aids in holding the cardiac malady at bay. Nervous people with
valvular disease do badly ; their excitement tells on the heart. Worry
is even worse. Absence of worry means generally long life ; worry,
short life.

The sixth condition I laid down for the treatment of valvular disease
relates to the secondary results of the cardiac affection. With these it
may be proper to consider some special heart symptoms which are at
times of unusual prominence. But the attacks of palpitation and cardiac
pain ; the tendency to syncope ; the dyspnoea ; the dropsies ; the affec-
tion of the kidneys; the headache and vertigo; the insomnia; the
plugs that are washed into brain, or lung, or spleen, or liver ; the hepatic
engorgement; the catarrhal affections of stomach and upper bowel,
furnish so many morbid states that it would be impossible here to con-
sider them, or their management. I will only select for discussion a
few, and try to make clear some points which I have learned by
experience.

As regards palpitation in cases in which it is marked, we are often
met by this difficulty, that it gives a fictitious strength to the impulse.
We ask ourselves, whether it would not be better to treat such cases by
sedatives? Yet the pulse, though rapid, does not correspond in strength
the heart is really weak, laboring; and we shall rarely be wrong in

448 DA COSTA, VALVULAR DISEASES OF THE HEART.

meeting the symptoms with ammonia, with brandy, and with similar
agents. Then we notice a class of cases in which palpitation is not un-
common, but in which the action of the heart is sometimes rapid, at
other times slow, and is very much influenced by the least fatigue. This
may happen after some illness, other than cardiac, or after mental
anxiety. There is a functional cardiac disorder, superadded to the
organic malady, which may, indeed, show fair compensation, and really
be but slight. Great attention to the general health, with rest, will
get rid of the added marked functional disturbance ; and occasional
doses of bromide added to digitalis, if this be not otherwise contra-
indicated, a course of cannabis indica, or of arsenic, will show good
results. From opium, too, given in small amounts, we are apt to
observe a happy influence.

In yet another class of cases we have a constant sense of cardiac un-
easiness or actual pain as a striking symptom. In such the iodides
usually do good, also wearing a plaster over the heart. It may be that
plasters, as Lauder Brunton suggests, act simply by pressure ; but, at
all events, they act. In instances in which there is decided force to the
impulse, I often order aconite plasters, of half strength ; in other in-
stances, belladonna plasters ; and the relief they give makes the patients
very willing to repeat them. But the best of all remedies is nitro-
glycerine. It is most unfortunate that this valuable agent, which lessens
blood pressure and diminishes the resistance the heart has to overcome,
and which, therefore, ought to have so large a field of usefulness in
valvular disease of the heart, is so repugnant to many patients, and
produces headache so readily that it has to be discontinued. Yet those
who can take it reap the benefit. I have refrained from quoting cases in
detail, but I cannot forego citing two striking instances of its favorable
use, and in one of long continuance of its administ ration.

Mr. A., seventy-one years of age, was obliged to retire from the man-
agement of a large business on account of shortness of breath and
constant, dull pain in the cardiac region. He was also much annoyed
by dyspeptic symptoms. He presented a mitral incompetency with only
slight compensatory hypertrophy ; indeed, the impulse was not strong.
He had used many remedies, and did not tolerate digitalis well on
account of its disturbing the stomach. Drop doses of nitro-glycerine,
increased to two drops three times a day, removed in a few weeks the
cardiac pain. Stopped the intermittent action of the heart, and did the
dyspnoea more good than anything else, lie was able to resume his
occupation, reverting to the remedy as he thought he needed it.

Bus, EL, fifty-five yean of age, had a terrible record with reference to
disease of the heart. Ber grandfather and father had both hem
tremely gouty, and there was reason to think had had disease of die

heart. TWO sisters had died of valvular disease. She herself had had
SW0lkn feet when a young woman, and other evidences of gout. But
tie m subsided ; and, as years passed by, the large joints and the muscles

DACOSTA, VALVULAR DISEASES OF THE HEART. 449

troubled her. and she looked upon herself as rheumatic rather than as
gouty. Y. t she never had au acute attack of rheumatism. She was fond
of travelling, and I did not see her at times for long periods. But five
years before her death I am certain that she had no cardiac malady ;
for, knowing the history of the family, I examined her with reference
to this point. She went to Europe two years subsequently, and about
that time began to notice that she could not go up hill without panting.
While at Homburg, about eighteen months before her return home,
she had an attack of angina, for which nitro-glycerine was ordered, with
relief. A subsequent and more severe seizure six months afterward at a
railroad station, after some exertion, caused her to take the remedy
regularly ; and she soon learned that, if she persisted in its use, she had
neither attacks of angina nor the steady cardiac pain from which she
suffered. She kept on with the medicine, in the shape of tablets of s^th
of a grain, twice daily, rarely oftener, for a year, stopping it only for
short periods. She had mitral regurgitation with very moderate hyper-
trophy ; tendency to pulmonary congestion and to bronchial catarrh,
scanty urine with some albumen, never exceeding one-fourth of the fluid
in the test-tube, sleeplessness, and swelling of hands and feet. The heart
was made more regular, and the dropsy speedily relieved by digitalis and
acetate of potassium. Indeed, it was kept away by this, with the occa-
sional substitution of caffeine. Under these remedies alone, however,
the cardiac pain began to return ; toward the close the weakening heart
had to be sustained by the free use of brandy. For her oppression and
miserable nights, dry cupping and Hoffmann's anodyne proved at first of
service ; she had, finally, to take full doses of morphia. The tablets of
nitro-glycerine were not abandoned until near the end. She died coma-
tose.

One of the most important of the secondary results of the cardiac
malady is the diminution of the quantity of the urine. Not nearly
enough attention is paid to this point, and, unless the urine be albuminous,
it is not thought to be of any service to take its state particularly into
account ; yet it is very valuable to do so. Scanty urine, often of higher
specific gravity than normal and full of urates, will go hand in hand with
cardiac pains, with headache, and with dyspncea. It is well known that
the shortness of breath in valvular disease does not always receive an
adequate explanation in the physical condition of the lungs. The ex-
planation may be partly found in the concentrated condition of the
urine, and, very likely, in some of its retained elements producing the
disturbance in the capillaries of the lung or the respiratory centre. At
all events, from a practical point of view, we observe that diuretics, in
the condition alluded to, are most valuable in relieving the pulmonary
distress ami the other symptoms. Of great service is caffeine, than
which, indeed, there is no better diuretic in cardiac cases, especially
those with weak heart and concentrated urine, and which, also, up to a
certain point has the properties of digitalis as a cardiac tonic. The dose
generally sufficient is two grains of the citrate given every third hour ;
but it may be given in five grain doses, or more. Caffeine itself is

450 DA COSTA, VALVULAR DISEASES OF THE HEART.

advantageously administered, as was, I think, first suggested by Tanret,
in combination with benzoate of sodium in solution. I have found a
grain of each of these drugs mixed with syrup of orange flowers, or of
orange-peel, and water, each half a drachm, a good formula. Some of
the new salts which are very soluble, such as the cinnamate or the
phtalate, are also easily given. The former of these, as the sodio-cinna-
mate, contains sixty-two per cent, of caffeine ; the latter fifty-six per
cent., and is soluble in five parts of water. Both are adapted to hypo-
dermic use ; so is the sodio-salicylate.

Dyspeptic symptoms, due to a catarrhal condition of the stomach
and bowel, are very common in valvular diseases, especially in those of the
mitral and tricuspid valves. They may or may not be associated with an
engorged, torpid liver ; they may or may not be in the form of painful
digestion. In either case the failing appetite is apt to be treated by
tonics, often by iron. These are not, in my judgment, the right reme-
dies. I believe purgatives are; they strike directly at the morbid state,
and subsequently some bitter, or small doses of nux vomica, will restore
the desire for food. Purgatives are not given as often as they ought to
be in valvular disease of the heart. There is the fear of weakening the
patient; which they do not, if not abused. They not only remedy the
stagnation in the portal circle and remove the catarrhal condition, but
they lessen the liability to dropsy. The old treatment of an occasional
mercurial was good treatment ; and calomel may be beneficial in other
ways in disease of the heart, especially those with dropsical tendencies,
than through its diuretic action, which is now receiving so much atten-
tion.

It is impossible in examining the treatment of diseases of the heart,
whether of the disease itself or of its consequences, not to be struck
with the important part digitalis plays. And the question naturally
arises, whether any of the newer remedies can take its place? I have
tried them all, and I believe there is not one which is as trustworthy, as
valuable ; not one is at the same time so good a cardiac tonic and a
diuretic. But undoubtedly digitalis cannot be kept up uninterrupt-
edly, and it is apt to produce, after a time, derangement of the digestive
organs. Some cannot take it at all ; and as in any form of tonic, so
with this cardiac tonic, we get better results by occasional change.
I hold caffeine, strophanthus, and adonidine to be the best substitutes.
I have already spoken of caffeine. From adonidine I have witnessed,
in one-tenth to one-fifth of a grain doses three times a day, some admira-
ble results ; but more in cases of functional than of valvular disease of
the heart. Yet even here I have known it to act as an excellent heart
regulator. So does strophonthus, which I have, moreover, often seen
strikingly influence irregularity, and dyspnoea. Its action is very
rapid, but not so permanent as that of digitalis, and though much is

DA COSTA, VALVULAR DISEASES OF THE HEART. 451

claimed lor it as a diuretic, its influence in this respect is inferior both
to digitalis and to caffeine. It would seem specially applicable to cases
■with defective power and high arterial tension, as sometimes met with in
the heart lesions of Bright's disease ; but from actual experieuce I am
not yet certain on this point. Convallaria has, on the whole, disap-
pointed me in the treatment of valvular disease, though I think it is of
value in palpitation of the heart and in other forms of functional dis-
order. Cocaine answers very well in some cases ; it is certainly both a
cardiac stimulant and tonic and not devoid of diuretic powers.

A remedy which I am using now a great deal is chloride of barium.
Since I became acquainted, through the investigations of Boehm and of
Bartholow, with its physiological action and learned that in this it resem-
bles digitalis, I have prescribed it repeatedly in valvular affections. I find
it both a general tonic and a cardiac tonic, a remedy that increases the
tone in the bloodvessels, a fairly good diuretic, and one that can be
taken for a long time without disordering the stomach. It may be
even, as Robert1 shows, administered hypodermically. The dose in
which I have given it by the mouth is one-tenth of a grain in pill, three
or four times daily ; a rather larger dose is, however, admissible. In
very decided amounts it is apt to produce diarrhoea. As Bartholow
points out, it has many incompatibles, and it is best not to give it in
combination. Among its properties I have noted that it lessens cardiac
pain. I learned this from the case of an elderly gentleman with a
mural lesion, regurgitation with some narrowing and defective compen-
sation, in whose case pain or constant cardiac uneasiness was a promi-
nent feature. Digitalis did him in this respect no good and was losing
its effect in steadying the irregular heart. Chloride of barium in one-
tenth of a grain doses improved him greatly ; the oppression was
relieved, the heart became more regular, the cardiac distress disap-
peared. He has been more than once benefited for a long time by a
three weeks' course of the remedy.

I must not bring this paper to a conclusion without mentioning a
point of which I know the great value, — to make periodical examina-
tion of persons affected with valvular disease. I am not speaking of
those in whom serious symptoms call for constant supervision ; rather
of those who, under our advice, take little or no medicine. In them,
too, it is true that the heart of to-day may not be the heart of a month
hence. Yet they are the ones chiefly in whom beginning changes can
be most readily met, and whose lives, with the aid of treatment when
necessary, can be greatly prolonged. Let them be made aware of the
importance of skilled supervision. It will not mean needless interfer-
ence; it will mean judgment as to when interference is really helpful.

1 Therapeutic Gazette, June, 1837.

452 KEEN, CEREBRAL SURGERY.

In valvular disease, as in other instances of disease of the heart, ad-
vance in knowledge is demonstrating how the arrow in the side can be
kept from being fatal.

THREE SUCCESSFUL CASES OF CEREBRAL SURGERY.

INCLUDING (1) THE REMOVAL OF A LARGE INTRACRANIAL FIBROMA :

^2) EXSECTION OF DAMAGED BRAIN TISSUE ; AND (3) EXSECTION

OF THE CEREBRAL CENTRE FOR THE LEFT HAND ;

WITH REMARKS ON THE GENERAL TECHNIQUE OF SUCH OPERATIONS.1

By W. W. Keen, M.D.,

PROFESSOR OF 8CHGERY IN THE WOMAN'? MEDICAL COLLEGE OF PENNSYLVANIA ; 8URGE0N TO ST MARK'S,
ST. AONES'S, AND THE WOMAN'S HOSPITALS, ETC.

(Concluded from page 357.)

Case III. Epilepsy of uncertain origin; attacks beginning in left hand;
excision of cerebral centre for left ivrid and hand ; recovery in eight days ;
epilepsy improving to date. — W. B., of Maryland, aged twenty ; American ;
clerk in a country store. His best and present weight is one hundred
and thirty pounds ; five feet five inches in height. The patient is a
hearty young man, having had all the diseases of childhood except
scarlet fever. At the age of three years he had spasms for six hours
from indigestion. He had no subsequent attacks.

At the age of thirteen, he rose one morning at four o'clock to make the
fire, and after doing so fell asleep in a chair, from which he fell, and he
thinks he struck his head on the stove. He was unable to fix the loca-
tion of the blow, as there was no cut or bruise on the head. On waking
up he found himself on the floor dazed and suffering with headache,
which continued all day, but was not sufficient to keep him in bed. His
history is quite imperfect in detail. Ever since this accident (?) he has
had epileptic attacks, always preceded by dizziness. Stooping often
brings one on, he and his family say (though he could never accomplish
this before me). He has never had a hurl in consequence of these
attacks. Sometimes they occur in the eight. He eats and sleeps well.
His friends state that the attacks begin with a fixed or a wild look from
the eyes, and when engaged in any action, such as tying a bundle with
twine, lie would continue the action for an unreasonable time, till he
would come out of the attack and resume his work as usual. His head
sometimes turned to one side and sometimes to the other before any
other part of the body became affected, then the arms would begin to
jerk, then the convulsion would become general. The fits would last
about two or three minutes, and would be characterized by very marked
convulsive movements.

Present condition, April 28,1888: Read. When the head was shaved
two small scars were seen, one from a recenl blow and one unaccounted
for; neither of them seemed important. On the right temple was a dis-
tinct furrow, which could be traced over the temporal muscle into the

• Read before the American Surgical Association, September 18. :

KEEN, CEREBRAL SURGERY. 453

temporal foes*. It began one-quarter of an inch to the right of the
middle line, and seven-eighths of an inch in front of the bi-auricular line,
terminating below one and one-quarter inches in front of the bi-auricular
line and one and three-quarters inches above the zygoma, and one and
one-half inches behind the external angular process. At first this irregu-
larity was thought to be the coronal suture, but it was so regular on the
edges and so sharply defined that it was thought to be a furrow, and the
question was, Might it not be a fracture '! No such furrow existed on the
left side, where the coronal suture was detected with great certainty.
On the right side, the coronal suture, unless it was this furrow, was very
indistinct. The temporal artery lay posterior to the furrow.

Dr. Charles A. Oliver makes the following report on his ocular con-
dition.--: "April 24,1888. Direct vision for form, normal in each eye
separately. Range and power of accommodation in each eye, proper
for refractive error and age of patient. Visual fields normal in sequence,
though both reduced to more than one-third the average areas, those of
the right side being somewhat the smaller. No subnormal color-percep-
tion. Pupils normal in size and shape. Irides freely and equally mobile
to light-Stimulus, convergence, and accommodation. Very slight insuf-
ficiency of the interni. Characteristic changes in the eye-grounds usually
seen in epileptic subjects with frequent seizures — i. e., a low and chronic
form of retinitis, associated with a dirty red-gray appearance of the optic
nerve : this being the more marked on the right side.

"Remark*. — From this grouping of eye-symptoms, which, with the
exception of the eye-grounds and their resultant visual fields, are nor-
mal, and hence negative in character, there can be but one legitimate
conclusion : a similar condition of the layers of the cerebral cortex, the
result of repeated convulsive seizures; the position of the greatest
amount of change (indicative of probable situation of irritation focus)
being indeterminable."

The friends of the patient insisted on something being done at once,
as they desired to take him home. I stated that I would make an explo-
ratory incision in the scalp, and if anything abnormal was found I would
go furt li er.

April SO, 1888. Operation. — An exploratory operation was done by
making a horseshoe-shaped incision with the convexity looking back-
ward, enclosing in its area the suspicious groove before alluded to.
Just before the operation another very careful examination was made,
and three facts noted of importance : First, the coronal suture could be
more distinctly made out than was at first supposed, and it lay behind
the furrow; second, the furrow bifurcated in such a way as to suggest
a bloodvessel; third, at the lower part of the furrow pressure caused
bulging corresponding to the furrow and again suggested a vein. In
view, however, of the preparation for the operation and the urgent
anxiety on the part of his friends, I deemed it best to make the explora-
tory incision. The most careful antiseptic precautions, as detailed in
I., were used, without the spray. Ether was the anaesthetic used.
No ergot or morphia was given, as I hardly deemed it probable that I
should do more than make an incision of the scalp. On lifting the scalp
from the skull nothing abnormal was found. The groove or furrow, so
particularly described, was found to be a vein, but I never before felt a
vein with such sharp, hard borders, and, until just before the operation,

VOL. 96, NO. 5.— NOVEMBER, 1888. 30

4f)4 KEEN, CEREBRAL SURGERY.

I was very doubtful as to what the furrow was. The patient made an
uninterrupted recovery without any rise in temperature.

When he had recovered his family changed their minds, and advised
that he remain here under my observation for treatment with drugs, or
another operation should anything be found to indicate its being desira-
ble. Accordingly I placed him under the constant care of two trained
nurses, who reported to me the character of each fit in its minutest detail.
Dr. Sprissler had already seen two attacks from the beginning, and
the nurses reported three others which were completely observed. All
five of the attacks were practically as follows: Each attack invariably
began in the left arm and fingers. The thumb and fingers became rigid
and extended, widely separated, the hand and arm in a right line and
the elbow flexed ; usually both legs were next attacked, the left usually
preceded the right and was crossed in front of it ; next the face became
attacked, the mouth being drawn to the left. (In one attack the mouth
wras affected before the leg.) After this the convulsions became gener-
alized ; the fingers of both hands flexed ; the pupils were first dilated
and then contracted. These attacks lasted from one to ten minutes.
The number of them was markedly increased immediately after the
operation of April 30th. Not unusually he would have one or two a
day, but they gradually diminished to their normal frequency. Finding,
now, that the fits began, so far as was observed, in the left hand, I deter-
mined to excise the centre for the left hand and wrist.

Operation May 30, 1888. Present, Drs. William Thomson, J. H.
Musser, F. X. Dercum, J. M. Taylor, J. K. Mitchell, Morris J. Lew is,
W. J. Taylor. His head was prepared on the day previous with the
usual precautions mentioned in Case I. One-eighth of a grain of mor-
phia and a drachm of ergot were given half an hour before the opera-
tion. During the etherization he had a fit, as was the case at the former
exploratory operation.

A curved incision, 3x3} inches, was made with the convexity looking
backward, the flap lying over the fissure of Rolando. This fissure
had been first marked on the scalp by Hare's and Thane's methods ;
the results of both of which were practically identical. In order to
indicate it upon the skull itself, two small incisions were made at the
upper and lower end of the line, and with a bone gouge two little nicks
were made in the skull through the openings. A one and one-half inch
trephine was now applied, the centre pin one-eighth of an inch hack of
the fissure of Rolando, the lower margin of the trephine being about a
quarter of an inch above the temporal ridge. The bone when removed
was placed in a cup of bichloride solution (1:2000). This cup was
placed in a large basin of hot water, which Dr. Musser was careful to
keep at 105°-100°. The bone and dura both appeared normal ; no
bulging was observed, and the pulsation was regular. The dura was
now partially incised and the brain exposed. The pia was very much
infiltrated with serum, producing an oedematous layer much obscuring
the brain tissue, especially the sulci over all this area. Two convolu-
tions, running obliquely from above downward and forward, ero-scd the
trephine opening entirely, while at the anterior holder a third convolu-
tion, apparently in a similar direction, was partially uncovered. Large
vein* ran in the pia over the sulci. An attempt was made to determine
which was the Rolandic Benin and which was the minor fis.-ure by
separating the convolutions and determining their depth, hut both the

KEEN, CEREBRAL SURGERY.

455

sulci exposed were about an inch deep. This, therefore, gave no clew
to the point desired. Depressing the brain exposed a further area under
the edge of the bone but gave no information of moment. An applica-
tion of the cyrtometer (disinfected) was then made to redetermine the
position of the fissure of Rolando. This ran in the middle of the three
convolutions before mentioned (Fig. 9). In order to determine the seat
of the hand centre a faradic battery was then used. The ends of
tin- wiiv were wrapped in borated cotton dipped in bichloride solution.
Stimulating the two posterior convolutions gave no results, even when
the current was perfectly perceptible to my hands and contracted my
muscles. On touching, however, the anterior one of the three convolu-
tions the hand instantly moved, the wrist (as observed by Morris J.
is) moving in extension in the midline and to the ulnar side at
different touches, and the fingers being extended and separated. Above
this centre were the shoulder and elbow centres, and below the face
centre, as described further on.

Fio. 9.

Diagram of skull. (Drawn by Dr. J. M. Taylor.)

S, Fisanre of SyWius. B, Fissure of Rolando. IP, Intraparietal sulcus. PC, Precentral sulcus. T,
Temporal ridge. I, II, III, the first, second, and third frontal conTolutions. The doUtd line represent*
the opening in the skull; a, b, c, are the three convolutions first exposed in the trephine opening.
The tkadad lout represent the portion excised.

The opening in the skull was now enlarged, chiefly forward and down-
ward, till it measured two and a half inches antero-posteriorlv by two
and a quarter inches vertically, so as to disclose this convolution (c) to a
larger extent. From the point of application of the centre pin (an
eighth of an inch behind the fissure of Rolando and one inch above the
temporal ridge) the opening extended forward one and three-eighths
inches, backward one and one-eighth inches, upward one inch, and down-
ward one and a quarter inches. In enlarging the opening forward I

456 KEEN, CEREBRAL SURGERY.

invaded the territory covered by the flap of the exploratory operation :i
month before. Under this area the dura was noticeably more adherent
to the bone than elsewhere.

The anterior border of this convolution (Fig. 9, c) was marked by a
fissure nearly parallel with the other two.' The portion of the convolu-
tion (c) containing the hand-centre, about one and a quarter inches long,
as ascertained by the battery, was then incised vertically above and below
with a knife, the lower incision being three-eighths of an inch above the
temporal ridge. The sulci in front of and behind this convolution had
been previously freely opened. The lower end of the portion to be taken
away was then lifted and the loosened convolution was cut away from the
underlying brain substance with a pair of scissors. While this was being
done the hand was watched, but no movement was perceived. The wires
of the battery were now again applied, while Dr. Lewis again observed.
At the remaining part of the convolution at the upper margin of the
excised portion, movements of the left elbow (flexion and extension) and
shoulder, especially of the latter, which was raised and abducted, were
noticed. Touching the part of this convolution remaining at the lower
border of the excised portion, produced an upward movement of the
whole left face, no one muscle being noticeable in isolated contraction.
The platysma was not contracted nor was the angle of the mouth drawn
downward. Touching the white matter at the bottom of the excision
produced again the movements of the hand. It was deemed, therefore,
certain that all the hand-centre had been removed. It was noticed that
the convolution immediately behind the part excised was somewhat
bruised in the efforts to open the sulci on that border.

Dr. Lewis now took a photograph of the exposed brain. Compara-
tively little trouble had been experienced from hemorrhage. An Esmarch
bandage had been applied to the scalp, but it, probably, was not drawn
tight enough, as a few of the vessels bled somewhat freely. These were
caught with hemostatic forceps and the bandage was removed. It had
been passed only twice around the head. In the brain itself the large ves-
sels were necessarily disturbed to a considerable extent and bled quite
freely. Cocaine (four per cent.) and hot water did good service, but for
the larger vessels ligation answered best. This was done with Kocher
catgut. The tying had to be extremely gentle, with even pulling of the
two ends, else the vessels would give way. The dura mater was now
replaced and sewed with fine chromic catgut, two bundles of horsehair
having been placed underneath it. The final oozing was so slight that it
was not deemed necessary to put a drainage tube under the dura. The
disk of bone and some fifteen pieces removed by the rongeur forceps were
now replaced on the dura. Two bundles of horsehair were placed between
the bone and tin- scalp and also a small rubber drainage tube posteriorly.
The scalp wound was then closed by fifteen chromic catgut sutures.
An abundant dry dressing of corrosive sublimate, rubber dam, and ■
bandage completed the dressing. The operation had lasted about an
hour and a quarter. When put to bed the condition of the patient was
satisfactory. As soon as he recovered from the ether he was quite violent
in his restlessness. Soon afterward he had an epileptic attack ushered
in by Staring eyes, then the left leg was crossed over in front of the
right and the body became rigid. In about a minute the fit was over.
No movement of the left hand or face occurred. Immediately after the
operation the left hand was found to be paralyzed as to all movements

KKEN, CEREBRAL SURGERY. 457

both of fingers and wrist. The elbow was paretic, the shoulder and face
perfectly unaffected.

At •; p. m. the dressing was changed as it was saturated to the margin
from moderate bleeding. Again at 3.30 v. m. May 31st. the wound was
redressed for the same reason. The oozing at this dressing was much
more serous and less bloody. At 12.30 A. M. May 31st he had another
epileptic attack lasting about a minute precisely similar to the last one,

lept that he rolled over on his abdomen.

Sltt, 8 a. m. (first day after the operation). The patient has been
perfectly conscious ever since he recovered from the ether. The only
physical change noted was the paralysis of the left hand, which was
unaltered. The pupils were unaffected. He slept some during the
night, but, on the whole, the night was restless and disturbed. A
catheter was used both last night and this morning. The urine was
normal in quantity and quality. He complains of discomfort, but states
that he has no pain of any moment. He was allowed nothing but ice
during the night, but this morning, as he was moderately hungry, he
was given some milk. Some rather violent retching followed the opera-
tion but it ceased later in the evening. The wound was redressed, as the
dressing was slightly moistened with bloody serum, and the drainage tube
removed. In the left hand each finger was recognized correctly, but
the two points of the asthesiometer were recognized as only one when
so far separated as the entire length of the finger or the entire breadth
of the hand. The right hand, however, is but little better than this, as
the two points are recognized on the fingers as one at two-thirds the
length of the fingers apart and about the same crosswise. His mental
condition is such, however, that I do not think this test reliable, saving
to show that the left hand, in a general way, is not so sensitive as the
right.

June 2 (third day). The wound was redressed although the dressing
was scarcely stained. Five out of the fifteen sutures were removed, as the
wound was sealed throughout its entire length, saving where the drainage
had been. All the horsehairs but six were removed; two of these going
under the dura and four under the scalp only. An enema to-day evacu-
ated the bowels satisfactorily. His urine is evacuated only by catheter
twice a day. The bladder seems to have lost its expulsive force. When
the catheter is inserted no urine flows except upon pressure over the
bladder. The amount is small — twelve ounces in twenty-four hours.
Its character is normal.

6th seventh day). In the last four days his temperature has fluctuated
between normal and 100'; the latter occurring at night. His general
condition could not be more satisfactory : his appetite is good ; his head
feels perfectly clear; and he has had no pain. On the fourth day the
wound was redressed and all the stitches removed. The wound was en-
tirely healed. A little oedema exists in the centre of the flap, and
pressure on it gives a sensation of resistance almost equal to that over
the rest of the skull. Up to last night the catheter had to be used, ex-
Oepting that he was able to pass his water when he took an enema; but
since last night he has passed it voluntarily though very slowly and with
little force. He has been up and dressed since the fifth day after the
operation. He is anxious to go down stairs to his meals, but on account
of the slight rise in his temperature I have not deemed it prudent. On
June 3d he had two attacks characterized as before. On June 4th he

458 KEEN, CEREBRAL SURGERY

had one more. The attacks are evidently becoming very much lighter
and less frequent. Yesterday and the day before he had two aborted
attacks. He, himself, is most annoyed by his left hand which is still
paralyzed, though twice there have been slight involuntary movements
in it. The elbow has entirely recovered from its slight paresis.

7th (eighth day). As his temperature had fallen to normal and he
was anxious to go out, I allowed him to walk to a barber shop and get
shaved. The left hand was still paralyzed.

The attacks after the second operation, as after the first, were increased
in frequency, but they were not so severe, and they now diminished
quite rapidly in severity, frequency, and duration, rarely exceeding one
or two minutes in length. At present in an attack the left hand does
not move, the eyes are staring, his right arm, legs and body stiffened,
but little muscular movement ; the mouth drawn to the right and the
head turns to the left.

18th. Dr. W. J. Taylor reported his temperature as follows: In the
right palm 37° C, the left hand 37.5° C, the right side of the head
37.7° C, and left side of head 37° C.

28th. I examined him carefully to-day, as he was to return home. His
skull is perfectly firm, as much so on one side as the other, with very
slight, if any, irregularity of surface where the pieces of bone were
replaced. Pressure produces no yielding or pain. Except for the two
scars one would not know that his skull had been opened. The fits have
become greatly diminished, occurring now only once in two to four or five
days, and then only of momentary character, practically petit mat. There
is no convulsive movement whatever, and his mental condition is more
satisfactory, inasmuch as he is more cheerful and communicative, and
far less morose and despondent than when he first came under my care.
His hand and wrist are still as before, but he has ceased to carry his
arm in a sling as he did for the first three weeks after the operation.

I made the following measurements : Right biceps ten and one-eighth
inches, left nine and three-quarters inches, right forearm two and one-half
inches below the olecranon ten and one-quarter inches, and the left nine
and three-quarters inches. Unfortunately I did not make any measure-
ments of the same points before operation. Whether this difference ifl
due to wasting or is simply a natural difference in his case of a smaller,
because less used left arm I am unable to say.

Electrical responses of all muscles of the arm, forearm, and hand
are equal and prompt on the two sides, both by faradic and by constant
current. Unfortunately circumstances made it impossible for me to de-
termine whether reactions of degeneration were present or not.

July SO. He writes that motion is beginning to return in the left hand.

Dr. George Dock examined the specimens of brain tissue and reports
as follows. In all three cases reported in this paper, I may add, the
specimens were placed in Muller's fluid the instant they were removed.

" The specimen was received in Muller's fluid on the day of the opera-
tion and examined in less than twenty hours after removal. It proved
to be part of a convolution cut off at a right angle at one (lower?) end.
at an angle of about 45 degrees to the surface at the other, and with a
smooth base. It measured, when fresh, 32 millimetres in greatest length,
10 millimetres in thickness, and 18 millimetres in depth. The surface.
from which the membranes had been removed, showed nothing unusual.
In making a series of sections of an average thickness of 5 millimetres,

KEEN, CEREBRAL SURGERY 459

a hemorrhagic spot, 3 millimetres in diameter, was found, in the lower
third, just below the cortex. Examined fresh, in Midler's fluid, this
■bowed : 1, blood corpuscles of normal color and outline ; 2, multipolar
cells, with no evident alternations; 3, nerve-fibres, with and without
double contours, showing no swelling of the myelin and no apparent
loss of it ; 4, bloodvessels. The smallest of these showed numerous
highly glistening -pots in their walls, the larger ones no alteration in
structure.

" Having been placed in the hardening fluid so promptly the specimen
was soon ready for staining. It was stained by both ammonia-carmine
and Weigert's method, the latter giving very satisfactory results.
Minute extravasations of blood were found in all parts. Most of these
are along the course of small vessels, some confined within the lymph-
sheaths, others of irregular shape among the fibres of the white matter
and in the cortex. There are no blood-pigment masses and no diffused
staining. The large hemorrhage mentioned shows blood corpuscles with
well-preserved nerve-fibres, free myelin in small globules and fine gran-
ular material. In sections from this part of the specimen there is marked
dilatation of the perivascular lymph-spaces. Some of these attain a
diameter of not quite one millimetre, being from two to three times as
wide as their main vessels. The capillary in them is often distended
and the mesh-work, plainly visible, encloses a few corpuscles ; in rare
cases, however, a large number. The vessels appear normal here as
elsewhere. The nerve-fibres are intact, as a rule. In a very few places,
in small areas, they do not appear. These areas are in the extreme outer
layer just beneath the surface, and when found I have also found small
hemorrhages beneath them. The main bundle of white matter shows
no diminution in size or failure of reaction to stains. The cortical layer
is unchanged, save for the hemorrhages. The ganglion-cells are present
in all parts of this layer. Some of them are very pale, but none show
atrophic or inflammatory changes. Many of them lie in spaces rather
larger than normal, which may be due to an oedema of the space, or to
the action of the hardening fluid."

REMARKS. — The first operation, in which the skull was not injured
and the flap readhered to the skull and the wound healed without
inflammation, teaches one important lesson — the marked lesion within
the cranium that may follow a slight traumatism on the exterior. As
I eKtended the bony opening at the second operation I wondered why,
all at once, the dura became so adherent to the bone. In a moment I
observed that this began just where I encroached on the area under the
first flap. As injuries increase in severity their intracranial conse-
quences must increase pari pasm, so that we can easily understand how
severe blows, even without fracture, may be followed by meningitis, or
abscess, or, as in Case L, by a neoplasm.1 Macewen (Med. News, Aug.
18, 1888; alludes to this and to the adhesion of the brain to the bone
very happily as "anchoring the brain" and points out its deleterious
results. I can hardly, however, concur in his inference that a higher

> Cf. Horaley, Amkr. Jours. Mkd. Sci., April, 1887, p 365, C*m- VII

460 KEEN, CEREBRAL SURGERY.

temperature at the site of the injury is a contra-indieation to surgical
interference.

The moment the brain was exposed the marked oedema was the one
tiling noticed. It extended over the entire area exposed. Over the con-
volutions the oedematous layer was about one-eighth of an inch thick, and
over the sulci three-sixteenths of an inch or more, so that the sulci were
at first very hazily seen. Whether this oedema was the essential lesion or
not cannot be determined, but, though the brain was carefully examined
by touch (in the sulci to the depth of one inch), no evidence of any tumor
or other lesion that might cause the oedema was found. The examina-
tion of the excised brain by Dr. Dock shows that this cedema was not
merely superficial, but extended into the brain tissue throughout all the
excised part, and doubtless beyond, how far beyond we can only guess.
Besides this, Dr. Dock found numerous hemorrhages, which he believes
to be recent, and probably due to the necessary traumatism in separating
this convolution from its neighbors and excising it. During the opera-
tion I noticed that the convolution back of it showed marked evidences
of bruising, though, of course, the manipulation was as gentle as possible.
Whether these hemorrhages would have occurred had the vessels been
entirely healthy may be easily a question.

But the most interesting question is, as to the location of the centre.
I sought for this in the post-Rolandic1 convolution just below its middle.
(Centres (a) (b) (c) in Ferrier's plates. See Gray's Anatomy, last Am.
edition.) There were three convolutions exposed by trephining, and the
line for the Rolandic fissure ran in the middle of the central one (Fig.
9, b). The fissures in front of, and behind convolution (b) were of equal
depth, and another, also of equal depth, existed in front of convolution
(c). On the whole, I am decidedly inclined to think that the sulcus in
front of (c) was the precentral or vertical sulcus, the one between (6)
and (c) the fissure of Rolando, and the one between (a) and (6) either
the beginning of the intraparietal, or, possibly, a retrocentral sulcus.
If I am right, the centre for the wrist and fingers which I removed was
in the pre-Rolandic gyrus, its lower limit being at three-eighths of an
inch above the temporal ridge, and its upper end where it fused with
that for the elbow 32 mm. higher up, and the shoulder still higher,
while the centre for the upper face was in the same gyrus immediately
adjoining the excised portion at its lower end. It* the reader will com-
pare Horsley's figures for these centres (Gray's Anatomy, last Am.
edition, and American Joubkax op "THE Mbdical Sciences, April,
1887), he will he struck with the accuracy of their representation.
None of the wrist and hand centre existed in convolution (6); whether

i I bftv*DM i Bm term " pre- Htui pet nolandte," instead of tin* more oommon ntmnof th ggrrt,

deeignrdly. Th«i Amur* of Rolando is M Important and well knowntli.it th«M names are instantly
understood, far more ao than "autirlorn.ntr.il" or "ascending frontal," etc.

KEEN, CEREBRAL SURGERY. 4r)l

any existed in the convolution in front of (c) or not was not tested
by the battery, bat in view of the complete palsy of the wrist and
hand it seems improbable. As one of the few instances1 in which
the results of experiments upon animals have been verified on man it is
most Important and gratifying, giving us new confidence in this impor-
tant method of research which has already done so much to make
cerebral surgery not only possible, but successful and promises so much
more in the future.

The higher temperature2 on the right side of the head so long after
operation together with the continuance of the fits, may not mean any-
thing discouraging for the future, yet it is in such marked contrast to
Case II. that I shall watch it with interest. Probably the oedema will
subside slowly. Certainly to date (August 12th), though he has had
occasional convulsive seizures and a number of attacks of petit mal, yet,
on the whole, he shows considerable improvement both as to number and
character of the fits, with a decided gain in mental status. By " com-
pensation," it is nearly certain that in time he will regain control of the
left hand through the other hand centre, a process already, in fact,
beginning.

General Remarks on the Operative Technique.

My experience in these three cases, as well as assisting at several
others, in the new field of cerebral surgery, warrants some general
remarks which I trust may prove of value.

1. Sharing the head. So important do I regard this that I would con-
sider no diagnosis as assured and no operation warranted that had not
been preceded by shaving. The unexpected and unknown scars found
have surprised me in other cases, as well as in those here related. Be-
sides this, no reliable mapping on the head of the cerebral fissures and
gyri can otherwise be made. These can also be now marked on the
scalp by the aniline pencil.

_'. Antueptii. Practically, the admirable rules laid down by Horsley
were followed, nor can they be too strongly insisted upon. (See details
in Case I.) No spray was used during any of the operations, though it
had been used all the morning in the room in the first case. It is also
especially noteworthy that on the day before I operated on the third
case, circumstances made it needful for me to operate on a case of cancer
of the colon with a fecal fistula and profuse suppuration. Dr. AVillliam
J. Taylor assisted me in both operations ; and our hands were, of course,
saturated with infection. After the bowel case we carefully disinfected
them with soap and water, alcohol and bichloride, and several times

1 Cf. Horsley'* paper, 1. c, pp. 358, 361, 362, and Macewen, Med. News, Aug. 18, 1888.
* The relative temperatures of the two sides of the head before the operation have been unfortunately
mislaid.

462 KEEN, CEREBRAL SURGERY.

repeated this during that afternoon and the next morning. No infection
followed in the brain case — a most valuable lesson as to antisepsis.

3. Anaesthesia. In all three cases ether, and not chloroform, was used,
and I saw no reason for any preference for chloroform.

4. Marking the bone. Whether to mark the site of a scar or other
lesion, or to fix the site of the Rolandic or other fissure of the brain, the
nicking of the bone by a gouge, through one or more small incisions in
the scalp, is a most useful preliminary to the horseshoe-shaped incision
for the flap. As soon as this flap is raised, all landmarks are lost, and
one can only " orient " himself by a reapplication of measuring instru-
ments, which probably have to be disinfected, or perhaps cannot be.
Moreover, in my first case, it enabled me, as related, to fix accurately
the situation of the tumor.

5. Access to the brain. The large horseshoe-shaped flap of scalp is
infinitely preferable to the old crucial incision. The large trephines
now used (one and a half, two, and even two and a half inches ) are also
a great help, and I think it a rule, almost without exception, that the
bony opening should be ample. Bergmann's opposition to operative
interference with large cerebral tumors, on account of the probable
consecutive oedema, from want of support by the skull, certainly cannot
hold good. In my third case the preexisting oedema will perhaps find
its best relief, indeed, from the operation. The success that has prac-
tically followed such operative procedures is its best vindication. Plenty
of room, both for observation and for work, should be had. A small
opening may defeat the very object for which we operate. A large
opening adds no additional danger to the brain, and even if as large as
in Case III., the integrity of the skull may be entirely restored. The
"surgical engine" may be very useful in rapidly increasing the size of
the opening, but it should be used by an expert (a dentist if the surgeon
himself is not accustomed to its use) lest accidental injury be done to
the brain. The chisel is not only needless but dangerous. It is quite
surprising, also, how far beyond the limits of the skull opening we can
feel and even see. The brain allows of gentle pressure very readily, and
the finger can be inserted an inch all around the opening. The incision
in the dura should also follow the margin of the bony opening (one*
quarter of an inch away) and not be crucial. It may then be replaced
and secured by catgut with ease. I have had some trouble in doing this
with the ordinary needles, and have had made a handled needle with a
sharp, short curve and an eye in the point. Probably a sharply carved
staphylorrhaphy needle would answer well.

6. Hemorrhage. For the scalp I used the narrow band of the
Esmarch apparatus in the second and third cases, as suggested by Dr.
M Allen Starr. In the second it answered admirably, but in the third

KEEN, CEREBRAL SURGERY. 463

was soon cast aside as unnecessary. Generally, I believe, it will be very
useful.

Hemorrhage from the vessels of the brain itself is one of the most
important of all the operative questions. Morphia, as a preliminary, is
useful, I have no doubt, as is also ergot, though I should give the latter
in a dose of fjij— iv rather than 3j, as I used. The effect of the cocaine
applied directly to the brain was certainly very good. I shall, however,
try it in a stronger solution (ten per cent.) in the next case. Very
possibly, also, antipyrin might be of use in the same way. All such
solutions, corks, bottles, etc., should be sterilized. I also used boiling
water cooled to 115° or 120° F., to check the hemorrhage, and I could
not see that its liberal use did any harm to the brain tissue. Pressure,
also, is a most valuable means. But, after all, the chief reliance must
be on the ligatures of catgut. They should not be chromicised, as that
lasts too long, and may be an irritant, but are best prepared in oil of
juniper and kept in alcohol (Kocher). In my second case I had no
difficulty in tying the vessels, but in the third, and especially the first,
their friability was such that the most delicate manipulation and equal
tension on the two ends were requisite for success. It is not the arteries
but the large thin-walled veins that give trouble. The cautery in any
form should never be used. If there be any trouble in securing vessels
of the dura or brain near the edge of the bony opening, this opening
must be fearlessly enlarged, so as to give ready access to them. If the
middle meningeal (or other artery, of the dura) cannot easily be tied
at the cut edge, or even in its continuity, a suture may be passed around
it by a needle passed through the dura, but the dura should then be care-
fully lifted so as to avoid any underlying veins. Weir has suggested
the application of clamps to the cerebral vessels for twenty-four hours.
My experience would make me doubt whether they would hold with
such friable tissues, and, if they did, the tossing about of the patient's
head might easily displace them, and possibly even involve great danger
to the brain itself.

7. Recognizing the centre sought for. Only in Case III. did I have a
definite centre in view. Ordinarily the gyri and sulci of the surface
would be a fairly reliable guide, together with the various methods now
Died for mapping these out on the surface of the skull. If in doubt,
the ordinary faradic battery will serve us excellently, as was shown in
this case. The response to the stimulation of various parts of the same
convolution wii immediate, undoubted, and in every way satisfactory.1
In order more handily to use this means of diagnosis I have had made
by Mr. Flemming this little rubber handle with two insulated poles, the

1 Cf. Horsley'iCase V., The American Journal or the Medical Sciences, April, 1887, p. 368

464 KEEN, CEREBRAL SURGERY.

stems of which, being flexible, can be placed near together or far apart
as desired.

8. Photography of the brain. This can readily be done by an ordi-
narily expert amateur. Dr. Lewis and I are both of the opinion that

Fio. 10.

the exposure should be practically instantaneous with the most sensitive
plates made. Even with such plates they may be under-exposed on a
cloudy day. But the danger of movement by the patient and the
constant oozing of the blood make it desirable to have the shortest pos-
sible exposure. Possibly the "flash powder " may be useful, but if em-
ployed the possible firing of the ether should be borne in mind. The
photography is scarcely any interruption to the operation in the hands
of a competent assistant. But I was disappointed in its results in both
my cases (II. and III.). It gave no good details owing chiefly, I think,
to the wet, glistening, curved surfaces and deep shadow at the point of
excision. I would prefer to have a rapid sketch made by a good artist
who understands anatomy.

9. Drainage. Combined tubular and capillary drainage answered
best in the brain, as elsewhere. The tubing should be removed, as a
rule, at the end of twenty-four hours. Whether it would have been
wise to do so in my first case, with evidences of increasing pressure, ia
even now, in my mind, doubtful. The horsehair may be removed in
three to five days. Everything should bend to the speediest possible
healing of the wound, thus preventing hernia cerebri and favoring a
quick recovery.

10. Replarr,,,, nt <>( th,- bone. This most interesting and valuable re-
cent addition to our operative procedure receives further encourage-
ment from the results of Cases II. and III. In the last the disk of bone
(one and a half inches) was replaced with about fifteen fragments bit t en
out by the rongeur forceps. The skull is so completely restored that
except for the scars and slight flattening one would not know that it
bad ever been trephined. Heretofore, when the dura mater has been
removed, the bone has not been replaced, but Case II. shows that even
then it may be done with ease by attaching it to the under surface of
the flap by chromic catgut. Of course, the small pieces cannot be so
utilized, so in Case III. I had a lamb in the adjoining room, and it' the
removal of the dura had been necessary and any large gap been made
by the rongeur forceps I meant to replace the trephine button and fill
Dp the remaining gap by another button from the lamb's skull, trimmed

• JAY, CESAREAN SECTION WITH OOPHORECTOMY. 465

by the rongeur to rait the opening. I find that the back of the lamb's
skull has nearly the same curve and thickness as man's, and will give
one good button from its centre or, at a pinch, two might be got from it.

I had no trouble with the large disks, and do not think it at all
needful to chop them up into small fragments as Macewen did. But if
the bone is to be replaced, the most minute care must be given to it from
the moment of its removal to that of its replacement by one of the assis-
tants, whose sole care it should be. I have recently had to remove a
similar one and one-half inch button from a case trephined by a friend.
By accident the button escaped observation for perhaps twenty minutes
or more after its removal, and so lost its heat, even if it did not
become septic, which seems not probable. It gave.no trouble for over
two months, hut then produced an abscess, headache, etc., which were
quickly relieved by its removal. It was entirely necrosed. It is, how-
ever, proper to say that the skull was unusually thick and almost all
compact tissue, and that, soon after the primary operation, the wound
had to be reopened for hemorrhage from the scalp. Even with the
utmost care, disks of bone, if chiefly of compact tissue, cannot always be
successfully replaced. I recently had to remove three such, much
smaller (one-half inch) buttons from one of my cases of trephining of
the lower jaw. Yet Dr. J. S. Miller (Medical News, liii. 136) has just
reported a successful case of reimplantation of one such button in the
same bone.

11. Rapidity of recovery. Case I., in consequence of the reopening of
the wound and later complications, was long in getting well ; but Cases
II. and III. were out on the street on the seventh and eighth days, their
highest temperatures having been 99.8° and 100° respectively ; Case III.
with but little, and Case II. with absolutely no pain and no medicine.
No iodoform was u<vd. I get better results without it and its abomina-
ble odor.

Thanks chiefly to vivisection and antisepsis, cerebral surgery will show,
within the next few years, triumphs as exact, extraordinary, and benefi-
cent as has abdominal surgery.

- 1 keet, August J7, 1888.

CESAREAN SECTION WITH OOPHORECTOMY.

REPORT OF A SUCCESSFUL CASE.

By John G. Jay, M.D.,

PROFESSOR OF AMATOMT AND OPERATIVE 8TRGERY IN THE WOMAN'S MEDICAL COLLEGE OF BALTIMOKK.

Since the earliest history of gastro-hysterotomy this operation has
occupied a position of preeminent interest in obstetrical surgery. It was
probably first brought to notice at a very early date, and may have had

466 JAY, CESAREAN SECTION WITH OOPHORECTOMY.

its origin in aceident, being afterward improved upon by the surgeon.
The number of authenticated so-called "cow-horn cases" would lead to
this supposition, and it is a remarkable fact, that eight out of eleven of
them have recovered.

The operation is said to have been done by the Greeks, but only after
the death of the mother. A Roman law required the section to be per-
formed under the same circumstances — i. e., death during pregnancy, but
as it appears never to have been done at that day upon living women,
it is probable that Julius Ciesar was not delivered in this manner as is
by many supposed, for, according to Seutonius, his mother was yet alive
at the time of his invasion of Britain.

The term Csesarean operation, by which it is known, is therefore prob-
ably derived from the verb ccedere, and those persons so brought into
the world were called Csesones or Csesares. As it was something remark-
able to have been thus delivered, great men were not loath to have it
believed that they were Csesares. Hence the term gradually became
indicative of distinction and eventually the synonym of imperator, and
even at this day the Russian and German nations call their monarchs
respectively Czar and Kaiser. On the other hand, the operation might
well have derived its name from being the most important one of sur-
gical obstetrics.

The operation on the living woman, it is said, was first done about
the beginning of the sixteenth century, and Bauhin states that a woman
was operated upon at Siegerhausen, in Germany, about this time by her
husband who was a cattle gelder; that she recovered, and afterward
gave birth to several children in the natural way.

Six cases are recorded by Harris in which women have operated upon
themselves, with five recoveries. Aisenstadt, of Novgorod, Russia, re-
cently reported the sixth case, which alone was fatal.

In many of the works on obstetrics the Ca?sarean section versus crani-
otomy receives full consideration, but contrariety of opinion among
authors of the same as well as of different periods is so great that it is
not surprising that the operation as now practised is of such recent
date. As a rule, craniotomy has at all times until very lately been given
by many odds the preference: gastro-hysterotomy being regarded as the
dernier ressort of midwifery. Even in recent literature this opt ration
i.- by many .Icpncatnl when the destruction of the child may save the
life of the mother.

In this work on midwifery, published in the early part of the present
century, Denman makes a statement to the effect that every woman
upon whom the operation is done will probably die; although he speaks
fkvorabry of the chances for the child. He also says, that, "from a
i:ition of the apparent cruelty of the operation, it was never per-
formed or even proposed and seldom talked of in England until about
that time."

JAY, CESAREAN SECTION WITH OOPHORECTOMY. 467

The disfavor toward the operation may well be understood when it
inted that of the first thirty Caesarean sections done in great Britain
but one woman recovered. At the same time the continental surgeons
were operating with wonderfully good results considering the methods
then pursued, as nearly fifty per cent, of their cases are said to have
recovered. This, however, is questionable. The disparity of results was
no doubt due to the English aversion to the operation, which postponed
the section until too late to be of benefit. At the present time the show-
ing for Great Britain is vastly better but until very lately the maternal
mortality has been as great as 79 per cent.

In the United states Dr. R. P. Harris, of Philadelphia, has with great
care collected data relatiug to 170 cases which resulted in saving the
lives of 65 women. This is, however, a frightful mortality. The figures
include all operations, as far as known, which have been done in this
country ; those done without regard to antiseptic measures, as well as
those in which improved modern methods were employed. If these cases
be divided, and such as have been treated according to strict principles
of antisepsis, with other modern improvements, be grouped, we have a
very much better exhibit.

According to the same authority, of eight operations in this country
in 1887 four saved the women and of the children five were also saved.
In one of his letters he tells me that the operation which I shall report
in this paper was the second Caesarean section done in the State of Mary-
land and the first to save the life of the mother. I have recently learned
that mine is the third in order, although the first successful, and the first
Sanger. Drs. P. C. Williams and G. Farnandis did the operation at the
almshouse about the year 1859. The second by Dr. James W. Butler
was done December 20, 1869, and since my operation two more (Sanger)
have been done in this city.

Dr. Harris mentions also five cases of laparotomy done in the State
of Maryland after uterine rupture, which were therefore not Caesarean
ions. Three of these were fatal to the mother, the children being
dead. One doue by Dr. John H. Bayne in 1856 saved the mother ; the
child was dead. With similar result was an operation done by Dr.
Butler in 1869.

Dr. Harris's statistics are of the greatest interest and value, and they
prove what a benefit the modern or Sanger operation has been to an
unfortunate class of parturients. His record of the first fifty cases in
Europe and the United States is as follows :

Women saved 34

Children extracted alive 45

Women lost 16

Children extracted dead 5

Operators 31

468 JAY, CESAREAN SECTION WITH OOPHORECTOMY.

The first fifty cases in Continental Europe alone show a still better
record.

Women saved 39

Children extracted alive 48

Women lost 11

Children extracted dead 2

Operators 29

In the last half of each of these series the per cent, of recoveries is
higher than in the first, and this fact is full of promise for the future of
the improved Caesarean operation. In the past two or three years the
per cent, of recoveries has wonderfully increased in the United States,
and there is reason to hope that it will rise still higher. The secret of
this improvement in the results of gastro-hysterotomy lies in the fact
that latterly greater efforts have been universally made for the employ-
ment of better methods. Men in various countries, widely separated,
have been devoting their best energies to the same ends. Since the reve-
lation of Koch and others, relative to microorganisms, all surgeons and
obstetricians have been keenly alive to the importance of the exclusion of
septic germs : but, besides this all-important item in the treatment of
wounds, there are others, among which not the least is the acurate and
proper coaptation of surfaces. It indeed seems strange that an operator
would ever open a gravid uterus without making an effort again to close
the incision ; yet the idea of suturing the gaping wound* did not appar-
ently occur to the early operators, but contraction of the organ alone
seems to have been relied upon, and until quite recently some cases
have been thus treated.

The indications for gastro-hysterotomy should in every case be well
assured, for the risks of the operation are by no means few even when
the most perfect methods are employed. They may, however, be not so
great as in craniotomy, in cases unsuitable to that operation. All
a horities agree that when the conjugata vera is two and a half inches
or less, delivery of a head of ordinary diameters becomes impossible
without craniotomy ; indeed, embryotomy may be necessary, and these
expedients are more or less difficult and dangerous. Here, then, is in-
dicated any other operation which will yield as good or better results to
the mother and which may, at the same time, save the life of the child.
I believe that the improved and modernized Caesarean section is such an
operation, and when there is a question as to the propriety of one or the
Other procedure, it should. I believe, always have the preference. This
is just the reverse of universal opinion upon this question of not a gnat
while since, and which has many supporters at the present time.

The reaction in favor of the Cesarean section as opposed to crani-
otomy and embryotomy is becoming more and more decided, and men
who formerly had a strong preference for the latter operations have,

JAY, CESAREAN SECTION WITH OOPHORECTOMY. 469

since the adoption of modern methods, reversed their opinions. In the
Annual of Universal Medical Sciences, for 1888, opinions cited from
various eminent sources would appear to indicate that the sense of the
medical profession is crystallizing toward a conviction that where there
is a question as to the propriety of craniotomy, or the modern Cossarean
section, the latter operation is one of election.

A number of instances have been cited in which women having had
the Csesarean section performed, have subsequently become pregnant and
given birth to children. The reason for the section does not appear, but
it could not have been due to very great pelvic deformity, otherwise the
latter deliveries through the parturient canal at full term would have
been as impossible as the first. Perhaps premature labor may have
been induced.

In those cases in which pelvic deformity is so great that gastro-hyste-
rotomy, laparo-elytrotomy, or any other maternal section is necessitated,
the woman ought never again to become pregnant. She ought not, if
possible to prevent it, be allowed the opportunity of becoming so. The
prevention of this was formerly a greater problem than at present.
Oophorectomy done at the time of the Csesarean section is the preventa-
tive. I know that the question of its propriety elicits a difference of
opinion, and in some instances circumstances may make it desirable to
refrain from it ; but in the main I believe the principle to be correct.
M re than one reason may be given for the sterilization of such cases.
Recently Gusserow has spoken of the possible danger of uterine rupture
in pregnancies succeeding the Sanger operation, as has been known to
happen after the older methods of hysterotomy ; and when there is
grave uterine disease he advocates Porro's operation. Probably he
would regard multiple myoma an indication for the last named pro-
cedure. The removal of ovaries and tubes or the ligation of the latter
as suggested by Dr. Garrigues in a recent paper, are simpler methods
than Porro's hysterectomy.

For a married woman, sterilization may be her only safeguard from
equal or greater peril in the future. That peril may come speedily. In
a few months she and her doctor may be again confronted by the dread
alternative of the Csesarean section, or the destruction of her unborn
infant. If seen in time, the induction of premature labor would be the
proper course ; but notwithstanding precautions, circumstances may be
such that the pregnancy is allowed to continue to maturity.

That oophorectomy adds a pronounced degree of risk to the patient's
life, I do not believe. As it may be so easily and expeditiously done,
and as it removes entirely a future danger, I cannot coincide with those
wlnse counsel is against it. Indeed, if the pelvis be very narrow and
deformed, it would to me seem culpable to allow them to remain. If, on
the other hand, the pelvis be sufficiently capacious to permit the passage

TOL. 96, KO. 5. — 30VEMBEK, 1888. 31

470 JAY, CESAREAN SECTION WITH OOPHORECTOMY.

of a premature, yet viable, infant, the requirements might be different.
Of this the operator must be the judge.

The pain in the pedicles, to which Dr. Garrigues refers in his recent
instructive article on " Improved Csesarean Section," may, I think, be
easily controlled by anodynes, which are required after all operations of
such magnitude.

Case. — About twilight on the evening of October 22, 1887, I was
called in consultation by Dr. E. G. Welch to a case of dystocia caused
by deformed pelvis. The patient, Maria Carter, colored, aged twenty-
seven, married, primipara, had, I was told, been in labor for more than
a week ; and since the previous Wednesday, October 19th, the pains had
been frequent and very severe, recurring every few minutes. On the
morning of Friday October 21st, the day before I first saw her, the
membranes ruptured, and later in the day the midwife in attendance
called in professional aid. The woman, I learned, is the oldest of four
children, the rest of whom died at an early age, but of what diseases I
could not ascertain. She is quite fleshy and of low stature ; her exact
height being fifty-five inches. Although she is apparently healthy now,
she bears evidence of rachitis ; for besides a deformed pelvis, her tibiae
are markedly bowed forward, and she has a slight lateral spinal curvature.

Previously to my seeing her Dr. 8. W. Seldner had been called in
consultation, and agreed with Dr. Welch that natural delivery was im-
possible, and that owing to the very deformed and contracted pelvis.
even embryotomy would be a difficult undertaking. Under these cir-
cumstances the Cesarean section seemed to be the procedure indicated.

Upon examination, my opinion was in accord with theirs. I found a
pelvis which, as well as I could estimate, was in its conjugate diameter
about one and three-fourths inches ; the promontory of the sacrum pro-
jecting forward to the extent of producing this diminution and of being
mistaken by the not very skilful midwife for the foetal head. Besides
this antero-posterior deformity, there seemed to be a lateral contraction,
but as to the extent it was difficult to form an accurate estimate. The
foetal head was beyond the reach of the finger, this being partly due,
as I afterward discovered, to the presence of a large interstitial myoma
in the lower segment of the posterior uterine wall.

I endeavored to induce the patient to be transferred at once to the
Hospital of the Good Samaritan, as her surroundings were much other
wise than favorable for an operation such as the one contemplated, the
house in which she lived being an ordinary negro tenement, by no means
neatly kept, and, as maybe inferred, far from aseptic. Failing to obtain
her consent or that of her family to have her removed to the hospital, 1
found that if I operated I should be compelled to do so where she was,
which seemed more humane than to leave her to her fate.

Owing to the lateness of the hour, it being already dark, and to the
fact that there was no gas in the house and no other means of obtaining
adequate illumination ; also that it was essential to cleanse the premises
and make other preparation ; it was found quite impracticable to do the
operation that night, and although I was fully aware that there was no
time to be lost, 1 concluded that the chances of success would be greater
by waiting until next morning. In the meantime I ordered that the
dusty carpet be removed, the floor scoured, and the walls and ceiling

JAY, CESAREAN SECTION WITH OOPHORECTOMY. 471

whitewashed. Upon my arrival on the following morning I found that
my directions had not heen fully carried out and that the walls remained
tmolrannod ; hut as it was now too late to do this I was obliged to operate
in nn apartment only partially prepared and consequently under circum-
stances quite unfavorable.

I mention these facts to illustrate the difficulties that are frequently
encountered in the houses of patients of this class, and also to show that
it is not absolutely necessary to success, as some have seemed to think,
that this operation when performed in a large city be done in a hospital.

On the morning of the operation the patient was in a much more
nervous and exhausted condition than on the previous evening; she
realized the peril she was in and her mental state was that of despair,
with a desire for a speedy termination of her suffering.

Having determined upon the so-called Sanger method, the patient was
anaesthetized with chloroform, and with the assistance of Professors
Ashby and Winslow, and Drs. Welch, Seldner, and Germon, the opera-
tion was performed.

The preliminaries consisted of catheterizing the bladder, thoroughly
cleansing the abdomen with soap and water, and, after drying, again
washing with a solution of mercuric bichloride 1 : 2000. Towels wrung
out of the same solution surrounded the exposed abdominal surface. A
dilute solution 1:6000 was used for the sponges. The hands of the
assistants were thoroughly cleansed with soap and water and then washed
with a solution of 1 : 2000. The instruments were immersed in a solu-
tion of carbolic acid of two and a half per cent. The sutures, both
it ami silk, were aseptic, and in every other respect the operation
was done with as great regard to antiseptic principles as circumstances
would permit.

The abdominal incision was made in the linea alba from the umbilicus
for five and a half inches toward the symphysis pubis, and was after-
ward extended upward for an inch and a half to the left of the
umbilicus.

The hemorrhage from the abdominal incision was slight, and was con-
trolled by compression forceps. The peritoneum was carefully opened
and slit with a probe-pointed bistoury between the index and middle
finger to the extent of the abdominal incision. It was not possible to
lift the gravid uterus from the abdominal cavity through the incision of
the length which I had made, and I hesitated to extend this, lest escape
of the intestines should prove troublesome. This accident, however, did
occur after removal of the infant, but they were covered by warm cloths
wrung out of dilute carbolic solution and replaced as speedily as possible.

Upon examination of the uterus the placenta was found to be attached
to the anterior wall, so that its section could not be avoided. Except
the anterior surface beneath which the placenta was attached, the uterus
was thickly studded over with fibroids of various sizes from that of a
filbert to nearly the dimensions of a pullet's egg. Even in the excepted
area there were several. Some of these tumors were intramural, others
subserous, and several of them were distinctly pedunculated.

Before opening the uterus it was carefully pressed upward into ami
maintained in the abdominal incision to prevent the escape of the in
tines and the flow of blood into the ventral cavity, neither of which was

472 JAY, CESAREAN SECTION WITH OOPHORECTOMY.

entirely successful. Section of the uterus was rapidly made to the extent
of five and a half inches, upon which there was a deluge of blood. This
was of short duration, as 1 introduced my hand, rapidly detached and
removed the placenta, and compressed the funis to prevent further loss
of blood from the child. As quickly as possible the infant was extracted,
head first, and passed to an assistant ; at the same time, another, intro-
ducing his hand into the abdomen, grasped the uterus around the supra-
vaginal cervix and in this manner constricted it until an elastic tube
ligature was applied. This could not be done until the infant had been
extracted.

The infant, a well-developed male, showed but feeble signs of life,
and although efforts were made to resuscitate it they were of no avail,
and it died after having given a few gasps.

As soon as the placenta was detached the bleeding to a great degree
ceased and was thereafter easily controlled.

The fibroids being so numerous I considered the propriety of remov-
ing the whole organ and appendages by Porro's method ; there being a
question as to whether the presence of so many tumors might not un-
favorably influence the result. I concluded to follow what I considered
as perhaps the safer course and allowed the uterus to remain. Before
dealing further with the uterus the broad ligaments were transfixed,
stout double ligatures passed and secured and with the curved scissors
both ovaries and tubes were removed. After dusting the cut surfaces
of the pedicles with iodoform, they were dropped back into the abdominal
cavity.

Attention was now again turned to the uterus. On the left side of
the incision and barely escaping section there was an intramural myoma
about the size of the last phalanx of the thumb, the presence of which
necessitated resection of the uterus to an extent equal to its width. The
peritoneum was therefore dissected from the uterus at the site of the
myoma for about an inch, this dissection diminishing in width as the
ends of the incision were approached. A segment of the uterine wall
corresponding to the extent of the peritoneal dissection and slightly
bevelled toward the median line was removed, as well as a redundant
strip of the membrane itself. On the right side the peritoneum was
dissected up to the width of one-third of an inch and the muacularil
was bevelled as on the opposite side. A continuous carbolized catgut
suture was next employed to close the mucous surface and including
the endometrium. The second uterine sutures were interrupted, eleven
in number, and of stout braided carbolized silk. These were entered
about half an inch from the incision of the muscularis and extended
down to, but did not include, the endometrium. On the opposite side
the sutures were brought out upon the peritoneal surface at the same
distance from the incision. The ends were drawn and clamped, but
left untied until the peritoneum had been carefully closed by thirteen
fine silk interrupted sutures which were passed in and again out of
the peritoneum on each side and which brought the opposing senilis sur-
ffcoei into dote and exact apposition. After this the deep sutures were
Ugated. The slight oozing of blood which followed the removal of the
elastic tube ligature was absorbed by a large soft, flat sponge ; it was of
no ■pedal moment and soon ceased.

r thoroughly cleansing the peritoneal cavity with water of a
temperature about 120° F. and dusting the line of uterine incision with

.JAY, - JSAREAN SECTIOX WITH OOPHORECTOMY. 473

iodoform, the raw surfaces of the abdominal parietes being lightly dusted
with the same, they wore brought together. This too was effected by
three sets .if sutures. The first was continuous, of fine carbolized catgut
and included the peritoneum only; next, twelve deep, interrupted, of
stout braided silk ; and lastly, a continuous superficial suture of fine
silk for the greater perfection of dermal coaptation. In the lower angle
of the wound, a rubber drainage tube seven-sixteenths of an inch in
diameter, and extending down to Douglas's cul-de-sac, was inserted.
The line of incision was abundantly covered with iodoform powder and
a compress of iodoform gauze, and relieved from tension by four broad
strips ot' improved adhesive plaster. A thick layer of borated cotton
secured by a roller bandage completed the abdominal dressing.

After washing out the vagina with warm carbolized water, the ex-
ternal genitals were well dusted with iodoform and a pad of borated
cotton applied to absorb the discharge ; with directions to renew this
when recpuired.

The operation occupied nearly two hours, much of this time being
consumed in the insertion of the numerous sutures. The patient wai
put to bed and bottles of hot water and hot smoothing irons applied.
She rested well, and late that night was comparatively comfortable with
fairly good pulse and temperature slightly above normal. On the fol-
lowing morning, October 24th, the pulse was 132 temperature 99.6°.
She had a slight amount of uausea, but very little pain, that being con-
trolled by morphia gr. one-fourth, which was administered with quin.
sulph. gr. iij, by suppository every three hours. The urine was drawn
with a catheter, and this continued to be done twice daily for several
days, until she could pass it herself. She was allowed crushed ice dur-
ing the night, but nothing more. In the morning she took a small
quantity of black coffee and later an ounce of milk with lime water and
ice. This was repeated several times during the day, and in the evening
as she seemed faint she was given a little brandy with mint and ice.

The lochial discharge was of the normal amount and appearance
and without any odor of decomposition. At each visit, which was at
intervals of five or six hours during the first few days, the perineal pad
was changed, and the pubes and vulva dusted with iodoform. At a late
hour in the evening of the day following the operation the pulse was
still 132 and the temperature had risen to 101.2°. Early on the following
morning, October 25th, the pulse had fallen to 108, temperature to 100".
In the evening at 6* o'clock the pulse was 118, temperature 99.8°.

For several days the temperature ranged from 99.8° to 101.4° and
even after three weeks was at times slightly above the normal.

On the third day after the operation she was again taken with nausea
and vomited several times. This was relieved by Creasot. gtt. j ; Acid.
hydrocyan. dilut., gtt. iv ; Aq. calcis, §ss; several doses given during the
day.

Her nourishment for two weeks consisted principally of beef tea,
peptonized beef, milk, and chicken boiled to a jelly. During the first
ten days she several times was taken with a depression or faintness about
3 A. m., for which I ordered brandy, ammonia, and larger doses of quinia,

474 JAY, CESAREAN SECTION WITH OOPHORECTOMY.

with relief. This condition was not due to want of nourishment as
might be supposed, for it would occur when she had taken food only
half an hour previously. Often in serious illness the vitality of patients
seems lowest about this hour, and so it was with her.

On the 28th of October I drew the drainage tube partly out, and cut
off about an inch and a half of it. October 30th another portion of the
tube was removed, and the next day the remainder. On this day also
the abdominal dressing was entirely changed, and the wound was found
closed by primary union, except just below the umbilicus, and of course
at the lowest end where the tube had been. All the sutures were
removed except three at apparently weak points, and fresh dressing
applied. The remaining sutures were removed at the next dressing,
after the lapse of four more days.

The following is a record of the pulse and temperature for sixteen
days after the operation.

Date.

}*U

Temperature.

A. H.

P.M.

A. M.

P. M.

October 23d .

98.7°

24th .

. L82

132

99.6°

101.2

26th .

. 108

118

100

99.8

<«

26th .

. 108

105

100

99.8

27th .

. 110

119

100.5

101

28th .

. 101

105

100.6

100.8

29th .

. 109

110

100

101.4

«(

30th .

. 100

100

100.8

100. s

(«

::i-t .

. OS

112

99.6

101.3

ovember 1st .

. 08

99.3

100.8

2d .

. 88

ino.2

lOII.S

3d .

. 06

100.2

101.3

<•

1th .

. 90

99.4

in.)

<«

.--tli .

. 98

100.1

101

6th .

. 89

'.)::

100.2

100.5

7th .

. BO

09.2

Far about two or more weeks the temperature remained somewhat
shove tlif normal, and on two days, November loth and 16th, it rose to
100.2°. On the loth it was 98.6°. From that time it continued about
normal. Prom the opening where the tube had hen ■ small amount
of purulent fluid oontinued to How for several weeks, when it ceased,
and the wound entirely closed.

During the latter part of the time that the tube was in the wound,

a quite sensitive induration developed in the left hypogastrium. This
induced me to remove the tuhe. as I was convinced that it was the cause
(rf it. The induration then became less sensitive and finally subsided.

That the drainage tuhe was the cause of the continued elevation of
temperature as well as of the local inflammation I have no doubt It

JAY, CJESAREAN SECTION WITH OOPHORECTOMY. 475

was probably the cause also of the faintness or depression above referred
to. In view <>t" this, the propriety of having used a drainage tube at all
may be questioned. My reasons for inserting it were several. On ac-
count of the numerous fibroids throughout the uterus I was not greatly
i i lent that the incision in this organ would satisfactorily unite. Also
mse the abdominal cavity had been opened in an atmosphere not the
most sanitary and the peritoneum had remained thus exposed for a con-
i able time, I was fearful of peritonitis, and deemed it safer to afford
this vent Finally, because abdominal drainage is advocated by Kehrer
in this transverse section of the lower uterine segment.1

Only a few days elapsed before I changed my opinion concerning the
propriety of using the tube, and it became the source of the greatest
anxiety to me. I felt that it should not have been put there, and yet I
feared to withdraw it, lest the irritation which it had already caused
might continue, and having no direct vent, a deep accumulation of pus
be the result. I therefore withdrew it very cautiously and by degrees,
requiring four days for its removal. The canal remained open for a
time, moderate purulent discharge continued the while and eventually
cicatrization followed.

I freely express my belief that the drainage tube was not necessary, and
that, it rather retarded the favorable progress of the case. It was of soft
rubber, had been treated antiseptically, and was liberally fenestrated.

I think that in a similar case I should not use a drainage tube again,
but if I concluded for any reason to do so, I should use a tube of glass,
or better, perhaps, of decalcified bone.

The location of placental attachment in this case was probably influ-
enced by the multiple fibroid condition of the womb, as these tumors
were found numerously disseminated throughout the uterine parietes
with the exception of the area occupied by the placenta. The largest
myoma was about the size of a turkey egg, though flattened, was in the
posterior lower segment of the uterus, and was intramural.

It is well known that the African race in this country is much more
subject to myoma of the uterus than the white. There is abundant
evidence of this in communities where there is a large negro population.
I have, however, never seen a case in which they were nearly so numerous
as in this.

The location of the placenta, the necessity of cutting through it, and
the sudden profuse hemorrhage which followed, lead to an inquiry of
the probable cause of death of the child. I think it is not difficult to
understand that the relative loss of blood from incision of the placenta
reater to the infant than to the mother. The relation of such a case
to an ordinary < Cesarean section, with placenta elsewhere attached, would

' Lwk. Edition 1885, p. 430.

476 JAY, CESAREAN SECTION WITH OOPHORECTOMY.

appear to be somewhat the same as one of placenta pnevia to a normal
delivery per via» naturales, in which two out of three children are born
dead, and about one of four mothers lost.1

It is difficult to estimate the exact proportion of the several causes
which, operating upon the infant, occasioned its death. The three
principal were, the prolonged and severe uterine contractions (these
having been sufficient to distort the head by driving it against the
deformed pelvis), the exhausted condition of the mother, and, lastly, the
profuse placental hemorrhage.

I shall say a word in regard to suturing the endometrium, as this is
not usually done and is generally advised against.

To make the deep or main sutures include the thickened mucous
membrane would be a gross fault, as contraction of the muscularis
would almost certainly cause them to cut through this soft and fragile
coat, thus leaving the sutures lax and the wound gaping, with most
serious dangers from various sources. If, however, the suturing include
the endometrium alone, it excludes the lochia from the wound and
makes the closure of the internal aspect of the incision more secure.
The only objection, I think, is the additional time required for it.

The separate suturing of the abdominal peritoneum I had done
before and had also seen it done in several laparotomies by my col-
leagues, Professors Winslow and Ashby. With a continuous suture it
requires very little time, and as peritoneal surfaces when thus brought
in contact unite in so short a while, the abdominal cavity is in this way
shut off from the external wound, and from danger. Then if from any
cause primary union does not ensue, if the abdominal sutures should by
any means become lax, or if collections of fluids occur in the line of
incision, the abdominal cavity is closed and the discharge escapes from
the external opening.

A point of interest in the subsequent history of this case, is that on
two occasions, the first about two months after the operation, the second
only three weeks since, she had a flow resembling in every way the
catamcnia.

In regard to her marital relations, she states that they are the same as
before the removal of the ovaries, and that she experiences no diminu-
tion of sexual inclination.

At this time, more than seven months after the operation, she has
increased largely in flesh, and her health and strength are excellent.

Juki 2, 1888.

1 I.uxk'i Midwifery. Edition 18*5, p 593.

LLOYD, DEAVER, FOCAL EPILEPSY. 477

A CASE OF FOCAL EPILEPSY SUCCESSFULLY TREATED BY
TREPHINING AND EXCISION OF THE MOTOR CENTRES.1

By James Hkndhii: Lloyd, M.D.,

VISITING PHYSICIAN TO THE NERVOUS AND INSANE DEPARTMENT OF THE PHILADELPHIA HOSPITAL :
INSTRUCTOR IN ELECTRO-THERAPEUTICS IN THE UNIVERSITY OP PENNSYLVANIA;

AND

John B. Deaver, M.D.,

SURGEON TO THE PHILADELPHIA, ST. MARY'S, AND GERMAN HOSPITALS, AND DEMONSTRATOR OP ANATOMT IN
THE UNIVERSITY OP PENNSYLVANIA.

Medical Report by Dr. Lloyd.

The following case was admitted into the nervous wards of the Phila-
delphia Hospital under the writer's care, early in the past spring :

J. W. G., aged thirty-five years, American born. Mother died of
phthisis, father of paralysis. Patient has had the usual diseases of
childhood. He denies positively ever having had any venereal disease.
"When fifteen years old he was struck on the head with a ball-bat, from
which blow he became unconscious and was confined to bed for one
week. Further details of his condition at that time are not obtainable.
His fits did not begin until six years after. Fourteen years ago he had
his first seizure while asleep. In this he bit his tongue. The question
arises whether this was his first fit, or whether really it was not rather
his first discovered fit by reason of the wound of his tongue. Probability
is lent to the latter supposition by the fact that many of his seizures
have been nocturnal. Nine months after this first discovered fit he had
his first seizure during the day. After this time he had them varying
in number and intensity until admitted to the hospital. He described
his seizure as follows : He would have a decided sensory aura com-
mencing in the fore and middle fingers of the left hand, extending up
the arm, through the neck to the left side of the head, when the convul-
sion would begin. He has stopped the aura at times, and thereby the
fit, by tightly compressing the wrist. The aura lasted quite an appre-
ciable time, and gave him ample notice of the explosion.

During the time of the patient's early sojourn in the hospital his seizures
were mostly nocturnal. He was conscious of many of these. He said
they lasted but a short time, involving, as a rule, only the left face and
arm, and that he did not always lose consciousness. He also said that
he has had occasional attacks involving both sides of the body, but his
accounts of these were not clear, and it is probable that his conscious:
was lost or obtunded in these greater attacks. The few minor attacks,
which happened in the daytime, occurred during the absence of any
trained or intelligent observer, but several of his fellow-patients confirmed
in the main his own account.

In order to render the diagnosis more positive and the description
more exact, Dr. F. W. Talley, resident physician, began a systematic
nocturnal watch upon the patient, without the latter's knowledge, sitting

1 Read before the American Neurological Association, at the meeting of the Congress of American
Physicians and Surgeons, Washington, D. O, September, 1888

478 LLOYD, DEAVER, FOCAL EPILEPSY.

up in constant vigil several nights in succession. During the first night
nothing was ohserved, although the patient said in the morning that he
was sure he had had one or two slight seizures. In the second night
Dr. Talley succeeded in observing a characteristic attack, which he
describes as follows :

The fit commenced in the left arm. The fingers were flexed over the
thumb, the hand flexed at the wrist, the forearm flexed upon the arm.
The head was drawn over to the right side, the right arm and leg then
became rigid. The head soon began to rotate to the left, the fingers of
the left hand relaxed, the mouth opened and was drawn to the left side
with the right angle depressed. As soon as the face reached the median
line a series of clonic spasms began in the left arm and left side of the
face. (In two of his most severe attacks clonic spasms were observed in
his right arm.) The pupils were widely dilated and fixed. Conscious-
ness appeared to be preserved, partially, at least, throughout. The spell
was of very brief duration. Following the fit there was well-marked
paresis of the left arm and left side of the face.

These memoranda by Dr. Talley very faithfully describe the main
features of the attack. The frequency of the seizures, on account of
which the patient had applied to the hospital, increased, and they oc-
curred both day and night, so that they were soon observed by the
nurses, members of the resident staff, and by several of the neurological
and surgical staffs, who were called in consultation. The greatest
number of seizures recorded in one day was twenty-eight, at which time
the patient seemed to be passing into a veritable epileptic status, being
confined to bed, and becoming very dull and altered in his mental con-
dition.

The paresis of the left face and arm at this time began to be very
noticeable. The face was relaxed, the angle of the mouth depressed,
and the right or sound side drawn over perceptibly. The orbicularis
palpebrarum muscle was not involved. The tongue was not paralyzed
"he pupils were equal and responded to light and accommodation. The
arm was perceptibly weakened, especially in the flexors of the fin:
and wrist, the biceps, and the deltoid. These muscles were not wasted,
and did not. present any reactions of degeneration. On those days when
the patient's fits were infrequent this paretic state of the muscles im-
proved considerably is the longer intervals, and was most marked just
after a seizure. There was no alteration or retardation of tactile sensi-
bility. An examination of the eye-grounds at this time by Dr.deSchwei-
aitz revealed nothing indicative of organic cerebral chai

The onset of these seizures, upon which special stt laid both

in the diagnosis and subsequent Burgical treatment, was always the same,
and verified by numerous observations. The left hand, especially the two
fingers, was toe seat of the signal symptoms, both sensory and ra<

and, however varied the extent of the convulsive wave in different seiz-
ures, there was never any variation from this constant initiation. The con-
vulsive area varied considerably, from a Blight twitching of the affected
and arm, with no apparent loss of consciousness, to an almost uni-

MU bilateral convulsive explosion, always worse, however, on the left

with decided obscuration of consciousness. This loss of conscious-
real as it appeared, for once after a s. .
ire, during which 1 asked him some test questions, he answered them
as he regained control of his muscles. The patient

LLOYD, DEAVER, FOCAL EPILEPSY. KT*fl

iplained but little of headache and said it had never troubled him:
the slight degree of it from which he suffered in the hospital appeared
t i be ;iu effect of his rapidly increasing seizures. Be had no gastric
irritability whatever.

emed very evident to my mind in studying tliis case that we had
a focus of discharge in the region of the junction of the middle and
lower third of the ascending frontal convolutions on the rightside, possibly
involving also contiguous portions of the ascending parietal convolutions
in which experiment seems to have demonstrated centres for the hand
and wrist. The nature of this irritative lesion did not appear very
clear to me, although I was inclined to think it might be old scar tissue
and thickened membranes, the results of his injury. I considered the
long duration of his affection to contra-indicate a tumor, especially as he
had neither headache, vertigo, vomiting, nor changes in his eye-grounds;
although the focal nature of the discharge and the more or less constant
paresis of the convulsed muscles were very suggestive of a new growth.
I saw no reason to doubt the man's sincerity on the subject of syphilis,
but I classed him with the rest of mankind and gave him the benefit
both of the doubt and the iodides. He did not improve. A consulta-
tion was held with my colleague, Dr. John B. Deaver, of the surgical
stall* and an operation discussed. At a subsequent consultation with
Drs. Deaver ami Sinkler the operation was decided upon, with the con-
currence also of Drs. Mills, Dercum, and de Schweinitz, who kindly saw
the case by invitation.

On the 12th of June Dr. Deaver operated in the presence of the
above-named physicians and with the assistance of Dr. J. William White.
The details of the operation and the surgical aspects of the case will be
narrated by Dr. Deaver. It had been decided beforehand that the inci-
sion should be simply an exploratory one in case nothing was discovered
in the membranes or cortex, unless by faradic stimulation we should
succeed in locating the irritative area in the cortex, in which case it
should be cut out. By following IMd's and Horsley's lines Dr. Deaver
exposed, with an inch and a half trephine, an area which appeared to
include both sides of the central fissure (Kolandic I in the region of the
junction of the lower and middle thirds of the ascending convolutions.
This area was afterward much enlar. ially in an anterior direc-

tion, by the Hopkins' modification of Kongier's for thing abnor-

mal what discovered in the bone, membranes, or cortex by gross

inspection The difficulty of identifying the parts was so great that ex-
ploit begun with a faradic current, and with very gratifying
results. Upon mradizing a p lint back of the fissure of Rolando, more
properly the wrist centre, according to Ferrier, muscular contractions
occurred as follows : turning in of the thumb on the palm, flexion of the
fingers, flexion of the wrist, extending to flexion of the elbow (biceps
action). I cannot say that it was verified topographically — i. p.. by appear-
ance of fissures and convolutions seen in the wound, what i :res
were here excited. It was behind what appeared to me to be the Rolandic
fissure. The difficulty of identifying fissures and convolutions in a small

480 LLOYD, DEAVER, FOCAL EPILEPSY.

trephine wound appears to me to be extraordinary. What is of greater
importance was, however, here accomplished ; the reproduction of the
exact muscular movements which occur in the fit. At a point farther
front and below, and in front of the fissure seen in the middle of the
wound (Rolandic?), faradic stimulation caused marked contraction of
the face-muscles of the affected side. The mouth began to contract, and
was drawn toward the left side with a tremulous motion, and soon the
tongue began to protrude toward the left corner of the mouth. Soon
the left thumb began to be contracted and adducted into the palm ;
then the fingers were contracted into the palm and about the same time
the face muscles began to contract more actively, while the head was
drawn to the left side, and the left eyelid began to work. At the same
time the hand was gradually closed, and contraction of the forearm and
arm began, while the latter was drawn from the side to an angle of
forty-five degrees (deltoid action), and contractions of the biceps oc-
curred. At no time in the course of these faradic applications, anywhere
within the area exposed by the trephine and forceps, did any contrac-
tion of the leg muscles occur.

I observed especially, in making these applications of faradism to the
cortex, that considerable areas of it did not appear excitable at all to
the strength of current employed, at least did not give muscular response
anywhere, while the two comparatively narrow points above mentioned
reproduced almost exactly the muscular contractions of the epileptic
seizures, and seemed to stand for more " centres " than the diagrams of
those who have experimented would allow to any such narrow areas.

In the absence of any visible organic lesion it was decided to excise
these portions of the cortex. The possibility of a sub-cortical tumor was
not ignored, but there was absolutely no evidence of such in any alter-
ation of the vascular supply or of the consistency of the brain tissue.
The parts did not bulge into the wound, nor was the color of the gray
matter in any way changed. Accordingly Dr. Deaver excised from the
region back of the central fissure a portion about twelve millimetres
square carrying the incision well down to the white matter. Two
smaller portions were removed from the excitable region anterior to the
central fissure. Further exploration by means of these incisions failed
to detect any tumor. My attention had not been called at that time to
the distinction which Franck1 makes between the faradic excitability of
the gray and that of the underlying white matter. This distinction is
that the gray matter gives rise to a series of clonic spasms in the
related muscles, epileptiform in character, continuing even after the
fnra.lism is withdrawn, while the white fasciculi, when faradized, cause
a tonic contraction which ceases at once on withdrawing the poles. I
am quite positive that the contractions caused in our patient by stimu-
lating the gray matter were epileptiform — and if my memory serves me,

1 W»M »nr 1m 1 M.. trice* da Cer»e«u, etc., par Ix> Dr Fran. -ni* Franck, Pari*, 1887,

p. 107.

LLOYD, DEAVER, FOCAL EPILEPSY. 481

at'w r this lapse of time, the white fasciculi at the bottom of the wound
were also touched and caused but a momentary tonic contraction.

The patient's condition after the operation may be briefly epitomized
as follows, prefacing with the remark that he was watched by compe-
tent observers day and night and the nursing records kept in a book.

It was observed from the first that he slept with his left eye partly
open. The legs moved freely and were never paralyzed. The left arm
was markedly paretic, lying quite flaccid by his side ; he would occa-
sionally raise it by taking hold of it with his right hand. His left face
was also paretic. Late on the first night he had his first convulsive
movement ; it was only a slight twitching of the left side of the mouth
which was thus drawn to left side. These twitchings of the face,
accompanied occasionally by twitching of the left hand and forearm,
continued at intervals during the first six days, when they ceased, and
the patient has never had any convulsive movement whatever since.
They were not so severe as before the operation, nor so widespread.
About the third day there was some stiffness of the fingers, which may
possibly be explained by irritation of the white fasciculi during the
process of healing of the cortical wound. There was at this time
according to the nurse's records, a difference in temperature of the two
sides, the left axilla being from one to one and a half degrees higher.
After one of his twitching spells the patient spoke of the spells return-
ing, but he never mentioned his aura.

On the fifth day his muscular condition was as follows : The flexors
of the wrist and fingers were almost quite paralyzed. The biceps was
much weakened. The pronators and supinators were paretic. When
told to raise the arm he would reach for it with his sound hand, and
when restrained in this he would raise the affected arm with a sort of
fling and evidently with the aid mostly of the shoulder and chest
muscles. All his attempts to move the paralyzed muscles, especially to
close his fist, were accompanied by analogous movements of the right
arm. All the muscles of expression of the left face were affected, as
well as the left side of the occipito-frontalis. He had control of the
orbicularis palpebrarum. When he laughed the muscles of the paretic
side appeared to respond almost as well as those on the sound side ;
which seemed to show that a cortical paralysis is not absolute as far as
a bilaterally associated movement is concerned. The patient is right-
handed and has never been aphasic.

From about the sixth until the eighteenth day the patient cannot be
said to have been at any time in his normal mental state. He became
dull, then lachrymose and incoherent, and for a part of the time had
marked maniacal delirium with hallucinations of sight and hearing.
The surgical condition did not seem adequate to account for this. The
operation and subsequent treatment had been conducted with strict
antiseptic precautions, and the patient never had a serious rise in tem-
perature. There appeared to be headache at times' as he frequently
attempted to pull off" his dressings. There was at this time much
M-deraa of the scalp. While he was at his worst there was some pria-
pism, and one of the resident physicians was confident that the patient
bad masturbated. I doubt if the patient in his condition at the time
was conscious of it. The pupils were dilated and the eyes expression-
less. There was once involuntary passage of urine. During his most

482 LLOYD, DEAVER, FOCAL EPILEPSY.

delirious and restless stage it was thought that he did not move his left
leg as much as the right, but if so, this was the only time the leg was
ailicted. His left face became much more flushed than the right.
From this ominous condition he began gradually to improve toward
the end of the third week, until he could sit up and so gradually began
to get about. By the end of the fifth week he was practically well,
and had recovered some of his lost muscular power.

The following memoranda have been made quite recently (three
months after the operation) of the patient's condition. He has had no
convulsive seizure, whatever, since his convalescence.

try condition. (Patient blindfolded.) In the left, or affected,
hand, he feels the slightest touch with the blunt points of an sesthesi-
ometer. There is no retardation. On the forefinger he does not des-
criminate the blunt points one inch apart, but he tells the sharp points
one-quarter inch apart. In the other fingers and on the right hand he
discriminates better. With weights varying from two to twelve ounces
patient is able to tell the heaviest by cutaneous pressure as well on
affected as sound side. (The paralyzed hand has a more delicate skin
from disuse.)

The patient is not able to distinguish form when an object is placed
between his forefinger and thumb ; thus he appears quite unable to tell
a small square object, a silver quarter, a silver dollar, a small flower, or
a penknife. It is evident, however, that this is not a sensory but a mus-
cular defect, because his fingers are still so paretic that he holds tl
small objects in the most awkward way, and cannot move or twist them
about in his fingers; hence he is not able to bring his sensory nerve
endings in rapid contact with the outlines of these things. This cannot,
therefore, be quoted as a proof that muscular sense is in the motor cortex.
His sensation to pain and heat is perfect.

Motor condition. With a dynamometer his right hand registers 1 HO,
his left hand 20. He makes a great effort, straining even with his fan*]
muscles. The paretic face is slightly flushed. He says there is no differ-
ence in the sweating. In the left face the tactile sense is quick and per-
fect. He cannot close the left eye by itself, but closes both together — a
further evidence that bilaterally associated movements are not lost in
cortical paralysis. The left face is still markedly paretic and the tongue
deviates to the left. The muscles especially paralyzed in tin' arm are
the flexors of the fingers. The forefinger and thumb are notably weak
and awkward. He has good control of the flexors of the wrist. The
biceps contracts firmly. He says he has a feeling of weakness about the
shoulder, and his arm moves awkwardly, but the deltoid and individual
muscles are apparently about normal. The regain of power is rather
greater than was expect*

Dr. Allen .1. Smith makes the following report of the appearances of
the excised tissue :

"• l'hive pieces were referred to me for examination; one governing arm
alone ami the other two arm ami face movements. Stained by Weigerl
method. Those sections from piece governing arm alone (post to fissure
Rolando), each showed numerous foci of infarction, apparently recent
and potsiblv due to some violence to the tissue during operation." There
u:1- possibly some degeneration in the cortical substance, but at most
very slight. In the large pieces governing arm and face (taken from
nor to fissure of Rolando) there is distinct degeneration of the lai

LLOYD, LEAVER, FOCAL EPILEPSY.

483

multipolar pyramidal cells, with the same foci of hemorrhage as in the
smaller pieces. A number of these large cells seem to be in a condition
approaching fatty metamorphosis, and small granular bodies, like fat

Fig. 1.

•

■?■• — '•». -

■

&> ■ ;• - -km

Microscopic drawing from portion excised posterior to fissure of Rolando, showing granulation and
shrinking of large multipolar motor cells. (Weigert stain ) (Drawn by Dr. Allen J. Smith )

drops, make up the bulk, which is less than usual, and in most cases
shrunken away from the walls of tissue about the cells. These degen-
erated cells refuse to take the stain as well as their comrades that are
undegenerated."

In closing the account of this case it seems proper to offer a few special
observations. As far as I am aware, there have been two cases operated
on in which no discoverable lesion was present and in which the irri-
table area was mapped out with farad ism and removed. There may, of
course, be others. The two to which I refer are one of Mr. Horsley's
cases,1 and one operated on by Dr. Keen, of Philadelphia. The proprk ty
of the operation is to be decided upon in individual cases, and cannot
yet be made the subject of a general rule ; it must depend largely upon
special features, as, for instance, the strictly focal character of the fits,
their severity and frequency, and the extent to which they destroy use-
fulness or jeopardize life. Macewen* discusses the propriety of removing

i British Med. Journ., April 23, 1887.

* British Med. Journ., August 11, 1888.

484 LLOYD, DEAVER, FOCAL EPILEPSY.

large wedges of brain-cortex, and lays much too great stress, it seems to
me, upon the evils of producing hemiplegia in trying to cure fits — to
which it may be said, in the light of this case that, first, in curing focal
epilepsy it may not be necessary to cut out such large wedges as to pro-
duce hemiplegia, and, second, the evils of a partial monoplegia are cer-
tainly not to be compared with the direful effects of frequently repeated
epileptic seizures.

Surgical Report by Dr. John B. Deaver.

J. W. G., on June 11, 1888, the day previous to the operation, had
his bowels moved freely with a saline purgative; his urine carefully
analyzed and examined microscopically, showing it to be normal ; and
his chest examined with negative results. He was given a warm water
bath, followed by a boric acid bath, then the entire scalp was closely
shaved, washed with turpentine and scrubbed with soap and water, then
washed with ether and alcohol, when it was enveloped in a towel wrung
out of 1 : 1000 solution of the bichloride of mercury. Here, I feel justi-
fied in saying that part of the success of all operations is attributable to
the careful preparation of the patient. During the operation the follow-
ing day, June 12th, the most strict antiseptic precautions were observed.

Operation, June 12th, 11a. m. The patient was placed on the table for
operation. A hypodermatic injection of one-quarter of a grain of sul-
phate of morphia was given immediately before the anaesthetic was
administered, the object of this being to contract the arterioles and thus
lessen the amount of bleeding. Chloroform was administered until the
patient was fully under its influence, when sulphuric ether was substi-
tuted and continued throughout the operation. In the presence of the
neurological staff of the hospital, and assisted by my colleague, Dr. J.
William White, I first mapped out upon the scalp of the right side of
the head, the seat of operation, the fissures of Sylvius and Rolando by
using Reid's lines (see Lancet, 1884, p. 359), which I will describe. First,
draw a line, which runs from the lower border of the orbit through the
centre of the bony meatus of the ear. To find the fissure of Sylvius, draw
a line from a point one and one-quarter of an inch behind the external
angular process of the frontal bone to a point three-quarters of an inch
below the most prominent part of the parietal eminence. Measuring
from before backward, the first three-quarters of an inch of this line will
represent the main fissure and the rest of the line the horizontal limb.
The ascending limb starts at the point indicating the termination of the
main fissure — i. e., two inches behind the external angular process, and
runs from this vertically upward, rorabotll an inch. The fissure of Rolando
if (bund by drawing two lines from, and perpendicular to, the base line
to the top of the head, one passing through the depression in front of the
< ar and the other through the posterior border of the mastoid process.
The fissure of Rolando is now represented by a line drawn from the point
of intersection of the posterior vertical line with the line connecting the
na-al eminence with the external occipital protuberance, indicating the
it longitudinal fissure, to the point of intersection of the anterior
vertical line with the line representing the fissure of Sylvius, upon cither
ride of which are the ascending frontal and parietal" convolutions con-
taining the centre pre wilhed to remove in this case.

LLOYD, DEAVER, FOCAL EPILEPSY,

485

I prefer Reid's lines to Broca's, Lucas Championniere's, Hare's, or
Wilson's method of locating the fissures, as I have proven them upon
the cadaver to be quite as correct as any of the others, and I think
simpler and more comprehensible; and again, as they map out more
fissures than do the others, as brain surgery advances they will be more
useful. Over and a little in advance of the middle third of the line
representing the fissures of Rolando after all the layers of the scalp,
including the periosteum, had been dissected up by making a large
horseshoe shaped flap, with its convexity downward and forward, thus
tavorintr drainage, a trephine one and a half inches in diameter was ap-
plied to the skull and a section of bone corresponding in size to that of the
trephine removed. Thus far both the soft parts and the bone were per-
fectly normal, there being not the slightest evidence of depression of the
latter. The dura mater, which now presented at the bottom of the
wound intact and normal, was incised and reflected, thus laying bare
the arachnoid and pia mater, both of which membranes to the naked-eye
appearances were healthy. Before incising the hemisphere (to make sure
we were over the proper area) Dr. J. Hendrie Lloyd applied electrodes
which had been wrapped with sublimated cotton, and which was lying
in a 1 : 1000 solution of the bichloride of mercury, to the surface of the
brain thus far exposed, with the result of bringing about movement of
the fingers and wrist but not of the forearm, when I, with a jpair of

Fio. 2.

Diagram showing relative position of portions excised. (Drawn by Dr. Allen J. Smith, j

Hopkins' modification of Rongier's forceps, cut away several small pieces
of bone from the anterior margin of the opening made by the trephine,
Dr. Lloyd again applied the electrodes when the forearm was flexed and
supinated, the angle of the mouth elevated, and the face muscles con-
tracted. A saturated solution of boric acid containing four per cent, of
hvdrochlorate of cocaine was now applied to the arachnoid and pia mater
to contract the bloodvessels of the latter membrane. With an ordinary
sized scalpel, held perpendicularly, three pieces of brain tissue, each
three-quarters of an inch in depth, were removed, one-half an inch

vol. 96, no. 5.— novembeh, 1888. 32

486 LLOYD, DEAVER, FOCAL EPILEPSY.

square in size, back of the fissure of Rolando, and two smaller portions
anterior to the Rolandic fissure.

The cut vessels of the pia mater were ligated with fine juniper-oiled
catgut, and hot water applied to the surface to check the oozing ; the
latter proved to be very efficient. A few strands of heavy juniper catgut
were placed in the bottom of the wound and the flaps of the dura mater
approximated over it and sutured with catgut. Again, a few strands of
heavy juniper catgut were placed in the wound, resting on the sutured
dura mater, the skin flaps approximated and sutured with silver wire.
The wound was dressed antiseptically (bichloride of mercury being used),
and the patient sent back to the ward.

The temperature of the patient after the operation was 97° Fahren-
heit ; in the evening of the same day 99° ; pulse 98 ; respiration 15.
Ordered milk and lime-water.

June 18. Temperature 99-f0, pulse 94, respiration 16. Dressings
not soiled ; bowels moved slightly. Ordered potass, bromide, gr. xx
every four hours.

14th. Dressings slightly stained ; wound dressed, when found to be
completely sealed. No discharge. Pulse, respiration, and temperature
normal.

15th. Dressings not disturbed. No pain. Pulse, respiration, and tem-
perature normal.

16th. Dressings slipped. Wound had to be dressed. No discharge.

17th. Patient not quite so well ; is restless, showing some evidence of
cerebral irritation. Complains of some pain in the head. Pulse 84,
respiration 16, temperature 100°. Wound dressed and found healthy.
No discharge. The scalp behind the wound is oedematous. Ordered
ice-bag to the head, and calomel, \, with Dover's powder, gr. ij, every
three hours.

18th, 11 p.m. Patient while asleep and dreaming tore off his dressings.
Wound dressed, when the inner dressing alone was found slightly stained
with bloody serum, otherwise healthy. Scalp still oedematous. Patient's
general condition much better. Bowels were moved after the adminis-
tration of a simple enema.

19th. Wound dressed, six sutures removed, allowing three to remain.
The pointsfrom where the sutures were removed were touched with solid
stick of nitrate of silver.

Slst. Patient more restless than the day previous. Pulled at the
dressings, necessitating a redressing of the wound, which was found free
from discharge, and healthy. Pulse, respiration, and temperature normal.

25th. Patient attempted to remove his dressings, but was not suc-
cessful. The dressings were removed, when the wound was found to be
boded. The three remaining sutures taken out, and the points corre-
sponding to the site of the sutures touched with solid stick of nitrate of
silver. The part of the scalp covering the trephine opening was quite
prominent, lad upon palpation fluctuation was detected. I made an
inei>i«>n into the scalp here at two points, evacuating Bloody serum only.
1 then introduced a small rubber drainage tube and dressed the wound.
Pulse, respiration, and temperature normal. Patient complains of no
pain; tongue dry; calomel and Dover's powder stopped. Ordered
whiskey half an ounce, two grains of quinine every four hours, and also
three drops of turpentine, in emulsion, every six hours.

LLOYD, DEAVER, FOCAL EPILEPSY. 4^7

•

. Wound dressed, drainage tube behaving nicely, very little dis-
charge.

. Bowels were moved after an enema had been given.

99th. Wound dressed. Still some little serous discharge through the
drainage tube. Stopped emulsion of turpentine, but continued with the
quinine and whiskey.

July 1. Bowels moved twice during the night. Patient comfortable
and doing well in every respect.

I. Wound dressed. Drainage tube removed.

■ '>il. Three weeks since the operation, patient allowed to sit up.

4th. Bowels moved.

>'>th. Wound dressed, very little discharge of serum from tract of
drainage tube.

Uth. Wound dressed. Still a little discharge of serum from tract
of drainage tube. No pain or tenderness on pressure. The pulsation
of the brain at the centre of the flap covering the trephine opening in
the skull is very marked.

17th. Wound all healed. No further dressing applied. Patient
entirely well. Walks about the hospital.

The deductions which I would draw from this case are that this, as
well as other cases, proves that excision of parts of the brain can be
done with, I may say, perfect impunity ; therefore, in the case of a lesion
the nature of which is doubtful, and which in a short time will destroy
the patient's usefulness if not his life, why not here, as well as in the
abdominal cavity, make an exploratory incision? I think our success is
due. largely, in these cases to the precautions taken in regard to strict
cleanliness.

Sin. i Mr. Macewen has practised putting back the button of bone
removed in trephining and obtaining union, you may ask yourselves,
Why did I not likewise ? Notwithstanding I had subjected the large
button of bone, as well as the small pieces removed in my case, to the
proper treatment, preparing them to be reposited, I did not think it
worth while to place back so large a piece, as I had seen this done in
the practice of two of my friends, and in both cases it necrosed and
had to be removed ; neither did I have at hand the proper instrument
with which to divide the large piece of bone into small pieces or resolve
it to bone-dust. Had I done the latter and placed it in the wound, it
would not have been safe, owing to my not having absolute apposition
of the flaps of dura mater, in which event, the brain would have been
subjected to irritation, from the presence of the small particles of bone.
The last examination made of this case, September 14, 1888, by Dr.
Lloyd and myself, shows the opening, with the exception of a point at
its centre, a quarter of an inch square, to be filled in with bone. At the
point referred to very slight pulsation of the brain can be detected.
Here we have had regeneration of bone from the periosteum, therefore,
I am now well satisfied with the course I pursued and feel sure that
before long the entire opening, made in the skull at the time of the
operation, will be closed by bony plate.

488 DABNEY, AN EPIDEMIC RESEMBLING DENGUE.

ACCOUNT OF AN EPIDEMIC RESEMBLING DENGUE.

WHICH OCCURRED IN AND AROUND CHARLOTTESVILLE AND THE
UNIVERSITY OF VIRGINIA, IN JUNE, 1888.

By William C. Dabney, M.D.,

PROrEMOR Or 0B8TETRIC8 AND PRACTICE OP MEDICINE IK THE UNIVER8ITY OF VIRGINIA.

On Tuesday, June 5, 1888, I was called to see Herbert P., six
years old; he had been taken suddenly a few hours before with
violent pain in the left side of the chest nearly over the region of the
heart. His temperature was 103°, and the skin extremely hot and
pungent to the touch ; his bowels were rather constipated, but not
markedly so ; there was no nausea, but very little appetite. His chief
complaint was of the pain in the chest, which was excruciating and
aggravated by the slightest movement, or by drawing a long breath.
Nothing abnormal could be discovered about the thoracic organs, how-
ever, on physical examination. One grain of antipyrine was given every
two hours until the temperature fell to 100° or the pain was relieved, and
one grain of calomel was ordered every four hours. A mustard plaster
was applied to the chest and strict quiet was enjoined, though this was
scarcely necessary on account of the increase in the intensity of the
pain with every movement.

On my visit the next day, I found this patient apparently entirely well,
but two other members of the family, aged respectively eight and three
years, had violent pain in the left side of the chest, and over the region
of the stomach ; the pungent heat of skin was very marked in both of
these cases ; the temperature in each rose to a little over 103° at noon,
but was only about 101° at 6 p.m. and there was some sweating, but.
singularly enough, the extreme heat of skin was very marked.

By the next day both of these children were well, but two others in
the same family were sick ; one of them was affected precisely as the
others had been, but the other, a little boy about a year old, presented
different symptoms. In his case there were two or three attacks of what
I suppose from his mother's account was spasm of the glottis followed
by alarming prostration. The spasm and difficulty of breathing had
passed off before I saw him, but he was still very prostrate, his pulse
Ik ing 128 and feeble. The prostration lasted forty-eight hours and
passed off with profuse vomiting.

There were in this family six children, five of whom had the dm
one, a little girl nearly seven years old, escaped, though she remained
constantly with the sick children. (It may be well enough to mention
that this little girl who escaped had whooping-cough just a year before,
and that, during a violent fit of coughing, she was taken with right
hemiplegia and aphasia; she gradually recovered from this, and in the
cours. of two months was apparently well, but a few weeks (trior to the
appearance of the epidemic she complained of severe headache and of
immbneaB in the right hand and arm, and there was a very marked
tendency to call things by the wrong names, and often she could not ex]
herself at all ; this lasted only a day or two, and she seemed perfectly
well when the epidemic broke out.)

DABNEY, AN EPIDEMIC RESEMBLING DIHOUB. 489

On June sth. I wit- called to see a colored girl about seventeen years
old ; her temperature was 103.6°, her respiration rather quickened, her
pulse 90, the skin very pungently hot, and the tongue slightly coated;
she had very little appetite, and her bowels had not moved for forty-
eight hours; she complained of pain in the left side over the region

;he heart, aud of some pain in the shoulder on the same side ; the
pain vu aggravated by movement. The attack in this case came on
a few hours before I saw the patient, the first symptom being pain in
the side which was quickly followed by fever. There was no enlarge-
ment of the spleen that I could detect, nor was the liver affected in any
way. I was told that there had been three other cases almost precisely
like this one in the same family. One of them, a boy fourteen years
old, was still Buffering with the pain and some fever, but at the time I
him his temperature was only 101.5° ; the other two children had
recovered. I did not see these cases again, but was told that both of
those who were sick at the time of my visit were well the next day.

The next case was a young man about twenty years old, a student in
the University of Virginia; he was taken suddenly with violent pain in
the left side of the chest, which was aggravated by movement or by
drawing a deep breath ; indeed, ordinary inspiration caused such acute
pain that his respirations were shallow and hurried. He informed me
that he was taken with slight chilliness, and then the pain and a feeling
of constriction across the chest; his temperature was lOS.S3, his pulse
100 ; physical examination revealed nothing abnormal about his thoracic
organs: his appetite was poor, but there was not complete anorexia:
his bowels were slightly constipated, but this, he told me, was his habit.
Turpentine stupes were applied over the seat of pain and fifteen grains
of antipyrine were given by the mouth. At 9 o'clock the next morning
the pain was very much better — in fact, there was no pain except on
motion — and his temperature was 99° ; he was given five grains of
quinine every two hours until twenty grains had been taken, and was
kept in bed. At 1 o'clock p. ML, there was a recurrence of the pain and
fever just as they had appeared on the previous day, but antipyrine
afforded prompt relief to both. At 6 p.m., his temperature was 101°
and the pain was only appreciable on movement. These daily exacer-
bations continued for six days, but becoming less intense each day.

These cases will give a fair idea of the epidemic as it prevailed in and
around Charlottesville, Virginia, and the University of Virginia. It is
unnecessary to report more of the cases in detail, but I shall refer to
others later, in order to illustrate certain features of the disease.

It may be well enough to state, before going further, that malarial
affections are practically unknown in this section of Virginia.

The number of cases which I saw during the first ten days of the
epidemic was twenty-nine, and of these I took full notes. I saw at least
as many more subsequently, but, being extremely busy with the final
examinations of the medical students, did not take notes of them.

The disease, as will be seen from what I have already stated, was
distinctly epidemic. It was not contagious, or, if so at all, only in a very
slight degree. I shall give my reasons for this opinion further on.

Two of my colleagues in the University of Virginia, Dr. Cabell and

490 DABNEY, AN EPIDEMIC RESEMBLING DENGUE.

Dr. Towles, saw cases of the disease, and Drs. Randolph, R. W. Nelson,
H. T. Nelson, Magruder, Flannagan, and others, of Charlottesville, had
abundant opportunities for observing the affection, and all agree that it
is a disease with which they had not previously met, and which had not
been described.

I propose now to describe the characters of the disease as I saw it.

1. Onset. — In every case which I saw the onset was sudden, and
usually violent. One little girl, about ten years old, the daughter of
one of my colleagues, was taken suddenly, on her way home from church,
with violent pains in the side, and within fifteen minutes there was very
decided heat of skin. In another instance the pain came on so suddenly
that the parents of the child did not credit her complaints until the
fever came on half au hour afterward, and was attended with so much
stupor as to occasion great alarm.

2. Symptoms. — In every instance pain was one of the first, if not the
first symptom, and the rise of temperature appeared shortly thereafter.
It will be well, however, to examine the different symptoms in detail.

a. The nervous system. In two cases there was a severe chill, which
immediately preceded the pain, and in several others there was chilliness.
The pain, however, was, by far, the most striking feature as far as the
nervous symptoms were concerned. In character it was usually sharp
and lancinating, and was much more violent when the patient attempted
to move or to draw a deep breath. (So agonizing was this pain that it
was nicknamed the "devil's grip" by a sufferer from the disease in
Rappahannock County, Virginia, and this name became a common one
there afterward, as I was told by Dr. W. F. Cooper.) There was slight
tenderness over the seat of pain in every case, but it was not nearly so
marked as the pain itself. The seat of the pain was usually in the left
side of the chest just below the nipple, but in some of the cases there
was pain in the opposite side, or in the shoulder of the opposite side ;
ami in a few of the cases, especially in children, there was pain in the
abdomen, usually in the epigastric region. In three of the twenty-
nine cases the pain changed from one point to another; in the cast of
one of my own children, for example, the pain was first in the left Bide,
and was attended with a temperature of 103° ; this lasted for twenty-
four hours, when they both subsided ; some hours later there was a
sharp attack of pain in the right side, without rise of temperature.

II "(ache occurred in nearly every case and was usually levere.
Backache was present in about half of the cases. There was no aching
in the limbs, as a rule, even when the temperature was high, though it
was occasionally present.

6. The circxdatory system. The pulse was always increased in fre-
quency, ranging usually from 90 to 110; in the cases of some of the
children it sometimes reached 120 or even a little greater degree of

DABN'EY, AX EPIDEMIC RESEMBLING DENGUE. 491

frequency. Physical examination of the chest revealed nothing abnor-
mal in the condition of the heart itself.

e. The rt'.yn'rutory system. The respirations were slightly increased in
frequency in every case, and were rather shallow, but this increase
seemed to be due entirely to the pain caused by drawing a deep breath.
There was no cough, and no expectoration, nor were any evidences of
disease to be found on physical examination. In two cases — the patient
in each being a young adult — there was a feeling of great constriction
of the chest. In one case — that of a child a year old which I have
previously mentioned — there was, I suppose, from the account which I
obtained from the mother, some spasm of the glottis, but I did not see
the child during any of the attacks.

(/. The digestive system. The digestive symptoms were, as a rule, not
marked. In nearly all of the cases the appetite was poor, but in only
two or probably three was there complete anorexia ; thirst was always
complained of during the febrile stage. Vomiting occurred in four
cases, but in no case was it persistent or troublesome, and in two cases
(children) it occurred just at the close of the fever, the patient having
a profuse sweat and falling into deep and refreshing sleep immediately
afterward. As a rule, there was slight constipation, and in two cases
this was quite troublesome, but in a few cases there was slight diarrhoea ;
in two cases, indeed, the diarrhoea was quite severe, but I think it
probable that it was due in each instance to some imprudence in diet.
In the case of a little boy, four years old, there was violent spasm of
the intestines, which could be distinctly felt through the abdominal
walls during the paroxysms as hard knots.

e. The temperature. In every instance there was more or less fever
usually ranging from 102° to 104°. In but one case was the tempera-
ture below 101°. And even in that it is probable that the temperature
had been higher for a short time before I saw her. The striking features
about the temperature were its rapid rise and its short duration. In
every case, so far as I could ascertain, the fever attained its maximum
within an hour of the time that the pain was first felt, and in only three
cases did it last more than twenty-four hours. It is worthy of note
that in each of these three cases the patients were fatigued by hard
study. In two of these cases the fever was intermittent in character
and came on at about the same hour each day ; in the third it was
remittent. None of these three patients, who were students of the
University of Virginia, had ever suffered from malaria ; one was from
Portland, Oregon; one from near Bristol, Tennessee; and the third
from Loudon County, Virginia

/ The cutaneous system. I have already mentioned the most promi-
nent of the cutaneous symptoms — the pungent heat of skin. I have
never seen this more marked in scarlet fever than it was in some of
these cases, and in one instance, a ladv who had nursed scarlet fever

492 DABNEY, AN EPIDEMIC RESEMBLING DENGUE.

patients expressed great anxiety lest she might again have to contend
with this disease, her apprehensions being caused by the extreme heat
of the skin. Even when there was some perspiration this heat of skin
was marked. During the earlier hours of the attack the skin was dry,
but later on, usually about ten or twelve hours after the outset, there
was some perspiration and occasionally a very profuse sweat.

g. The urinary organs. In none of my cases was there any evidence
of disturbance of the urinary organs, except a slight diminution in the
quantity of urine discharged and a slightly darker color than normal —
changes which are common to all forms of fever. No chemical examina-
tion of the urine was made, however, except for albumin.

3. Causes. — The first question which demands an answer is — Is this
disease contagious ? And it is not easy to give a positive answer at present.
It will be observed that there were five cases in one family (of six chil-
dren), and four cases in another family ; in a third family all the chil-
dren, four in number, had the disease, and it is especially worthy of note
that the four children just mentioned had dengue in Texas a year or
two ago. As a general rule, it attacked all of the children in a family.
But in a very large proportion of the cases which I saw there was no
evidence of contagion. Sixteen of the twenty-nine patients were students
in the University, and among these sixteen there was not a single in-
stance in which the disease could be fairly attributed to contagion.

In one house containing eight large rooms there were sixteen students ;
these young men were constantly together and yet there was but one
case in that house. In another similar building there were two cases.

It may be stated briefly that the cases among the students were scat-
tered in different parts of the University buildings, some of which are
half a mile apart, there being generally but one or two sick men in each
neighborhood. Nor could the extension of the disease be traced to the
association of the students in the different classes. For example, three
of the patients were medical students, five were law students, one was
studying civil engineering, and seven were students in the different
academic schools. The disease then, if contagious at all, would seem to
have been far less so than most of the contagious diseases.

Age was undoubtedly a predisposing cause; it was far more common
among children than among adults. I saw no case among the adults in
those families in which the children were sick with the disease. This, it
will be observed, is entirely different from dengue as it prevailed in
TeXM and other southern States some years ago. The weather was un-
usual for the month of June at the time of the first appearance of the
epidemic ; both days and nightl were cooler than usual at that season of
tin year— the nights being relatively much cooler than the days.

No causative connection could he traced between the previous condi-
tion of health and the attack, in any case; but among the students

DABNEY, AN EPIDEMIC RESEMBLING DENGUE. 493

those who were broken down by hard study had the disease in a much
more troublesome and intractable form than their less studious fellows.

There was nothing in the immediate surroundings of the patients
which could have caused the disease. The water-supply of Charlottes-
ville and the University is pure and abundant, and the sewerage system
of the University is well-nigh perfect. Nor was there anything in the
soil to which it could be attributed. Indeed, the epidemic prevailed
just as extensively three or four miles out of town, where the surround-
ings were totally different, as it did in the town or the University.

4. DlAOSOSIlC Features. — The striking features of the epidemic
here were : (a) The suddenness of the onset. (6) The seat and char-
acter of the pain, (c) The short duration of the fever. I have already
mentioned these features sufficiently in detail. The disease which, it
seems to me to resemble most, is dengue ; but it differs from it in certain
striking particulars, as shown by the following comparative tables:

In Dengue. In the Epidemic under Consideration.

Violent pain in the limbs. Rarely pain in the limbs.

Elderly people, as well as children, Confined to children and young adults.

commonly affected.

Joints are inflamed. Joints not inflamed.

There is an eruption. No eruption.

If Dickson's statement be correct, that one attack of dengue is pro-
tective against future attacks, we have a further evidence that the
epidemic described in this paper was not dengue, in the fact that four
at least of the patients to whom I have alluded had dengue in Texas a
year or two ago. The father of these children — a very observant man —
who not only nursed his children through their attacks of dengue, but had
the disease himself, assures me that while the epidemic which I have
described resembled dengue in some respects, it was in others totally
inilar and was clearly a different affection. The breakbone fever
which prevailed in Charleston, S. C, in 1880, resembled the epidemic
here in some respects, but there were striking differences ; for example,
Forrest states1 that " a symptom present in the majority of cases was a
cutaneous eruption ;" in not one of the cases which I saw or of which I
heard during the whole epidemic was there any eruption present ; nor
was there in the Charleston epidemic the same uniformity as to the
seat of pain as was observed here in nearly all of the cases ; there was,
it is true, in many of my cases, pain elsewhere than in the cardiac
region, but " the pain," as the patients themselves called it, was located
there, and that elsewhere was comparatively slight. Then in the
Charleston epidemic " there was no distinction of age, etc. ; " I did not
see or hear of a case here in a person over twenty-five years of age.
No one can read the accounts of dengue as it has prevailed in dif-

1 Amsbicax Jours a l or the Medical Semen, April, 1881.

494 DABNEY, AN EPIDEMIC RESEMBLING DENGUE.

ferent places and at different times, however, without being struck with
the great difference in the symptoms in the different epidemics. It
seems to me possible therefore, but far from probable, that the epidemic
which prevailed here in June last was dengue of which the symptoms
were modified by climate.

5. Duration and Prognosis. — The duration of the disease was very
variable ; in some cases a single paroxysm of twelve hours' duration
would end the trouble, while in others it lasted for days, and in two
cases as long as three weeks ; the pain and fever recurring daily and
usually at the same hour of the day. I have already stated that there
was no history of malaria in any of these cases. There was not a
single fatal case, but several of the patients whom I saw were left in a
condition of extreme prostration for two or three weeks after all fever
had ceased, and they would suffer pain in the affected side whenever
any unusual exertion was attempted.

6. Treatment. — The indications of treatment in every instance, so
far as the symptoms were concerned, were plain enough — to relieve pain,
to reduce temperature, and to prevent a recurrence of the paroxysm.

For the relief of pain antipyrine was usually employed, in doses of
from two to twenty grains, according to the age and weight of the
patient, and the dose was repeated every two hours till the pain was
relieved. It rarely failed to give relief within half an hour from the
time of administration of the first dose. In a few instances morphia
was administered hypodermatically, and opiates, generally in the form
of paregoric, were given to young children. One advantage possessed
by antipyrine over the other remedies which were given for the relief of
pain, was that it fulfilled the second indication, reduced the temperature ;
furthermore, it did not constipate or cause nausea as opiates often do.
In children a full bath, as hot as the little patient could bear, usually
afforded prompt relief, but other external applications, such as poultices,
mustard plasters, or other counter-irritants, did little or no good.

For the slight constipation, calomel was usually employed, and after
the paroxysm subsided or was relieved by the remedies which I have
just mentioned, quinine was given. The dose given to a man eighteen
or twenty years of age, was five grains every two hours till twenty or
occasionally thirty grains had been taken; to children smaller quanti-
ties were, of course, administered. I have already mentioned several
tiin< - thr pais upon motion or exercise which persisted in many oat
for days or weeks, in a few instances I gave salicylate of sodium with the
hope of relieving this annoyance, but there was no appreciable effect.

Antipyrine to relieve pain, calomel to relieve the CDnstipation, and
quinine to prevent a recurrence of the paroxysm, were the measures
which gave the best results, and late in the epidemic the patients would
often treat themselves with these remedies without sending for a physician.

REVIEWS.

A Clinical Atlas of Venereal and Skin Diseases, Including Diag-
nosis, Prognosis, and Treatment. By Robert W. Taylor, A M.,
M. D., Surgeon to Charity Hospital, New York, etc. Illustrated with one
hundred and ninety-two figures, many of them life-size, on fifty-eight beauti-
fully colored plates, also many large and carefully executed engravings
through the text. Parts I. and II. Venereal Diseases. Philadelphia: Lea
Brothers and Co., 1888.

A distinguished American artist has lately declared that no one can
by the aid of words alone so graphically describe a picture to even the
most skilful artist, that the latter can, without other knowledge, make
even the faintest attempt at a reproduction of the original. Here one
may estimate the disadvantages of the didactic over the clinical methods
of teaching medicine. There are few clinical teachers who surpass in
advantages the best portraits of disease. It is a marvellous matter that
the Atlases are not preferred, as they should be, above all the treatises.
It is, however, true that they are not. The Atlas before us furnishes a
fund of information of the most practical sort that is quite inaccessible
to one who has not enjoyed a large clinical experience and who is com-
pelled to rely on the printed page for the knowledge required in venereal
and cutaneous disorders.

In this matter of eye-instruction as compared with ear-instruction, the
savage is in advance of the scientist. Mr. Edouard Muybridge has
photographed an Indian blanket sent by LaFayette to France in the
last century, on which horses are represented with the anatomical
accuracy displayed on the frieze of the Parthenon, and recently demon-
strated to be faithful to nature by Mr. Muybridge's remarkable photo-
graphs taken instantaneously of animals in motion. One careful study
of a faithful portrait of disease is often worth more than reading a
learned essay on the same theme. The former is like the unconsciously
acquired familiarity with the features of an acquaintance ; the latter,
like reading his biography.

Dr. Taylor's admirable Atlas is so suggestive on many of the themes
that interest the modern student of medicine, that one might readily be
tempted to deliver a clinical lecture on the basis of the well-drawn
figures and carefully tinted illustrations which its pages spread before
the observant eye. Here are exhibited almost every one of the results
of the pathological processes occurring in the skin and the mucous sur-
faces of the body. There is scarce a figure in any plate that does not
surpass, in value to the student, all the writings of Boerhaave and some of
the more modern treatises by less distinguished men. It is easy to under-
stand, as we glance at the portraits thus faithfully drawn, why Mr.
Seymour Hadeo was so earnest in impressing upon his students in sur-
gery the importance of acquiring the art of drawing with a view to fix-
ing more indelibly in the memory the features of external disease. "The

496 REVIEWS.

modern Rembrandt," as he has been called, confesses to having himself
first engaged in his favorite work of etching merely as an aid to his
surgical work.

The illustrations before us are new and old, and we are in no fear of
contradiction when recommending the old with the new. Just in pro-
portion as the old are faithful, are they as good as, or better than, the
new. It is now nearly a half century since Rayer1 first gave his fine plates
of skin and venereal diseases to the scientific world, and was followed
by Tnistedt and Behrend,* who, with Dr. Taylor's commendable fore-
sight, availed themselves of the best that had then preceded. Fifty
years in one sense, is not a long period ; but in another it constitutes a
cycle, as, for example, in measuring the progress of the world's advance
in knowledge. When Rayer first published his plates, there was no
electric telegraph in operation ; and the entire modern system of postal
transmission was not yet conceived in the fertile brain of Sir Rowland
Hill. The whole pitiful career of the "Little Napoleon " was yet to be
a part of history. The works then written and studied as authoritative
in medicine are now, save for the collector of medical bric-a-brac, worth
simply the price of old paper per pound ! And yet, wonderful to relate
in comparison, but yet only truth to tell (for the truth of to-day is the
truth of to-morrow if only it be a real truth), Rayer's faithful plates of
external disease, copied, quaint costumes and all, by Triistedt and
Behrend, are not shown to be false by the brilliant portraits and striking
illustrations of disease furnished by our latest author! If one looks
with care, for example, at the excellent representation here given (Part
II., Plate XIV., Fig. 1) of the small pustular syphilide, he will find
there only the same syphilis portrayed by the eminent Frenchman a half
century before ! But if he studies it closely and with the careful scrutiny
of the medical artist, he will recognize a more definite purpose to exhibit
the exact shade of color, size, pustular apex, and physiognomy of the
individual lesion, with a pre-Raphaelite minuteness of detail, the general
effect being to produce a picture of the skin in disease which can scarcely
be surpassed in its value when one considers the needs of the physician.
I >r. Taylor's Atlas can be well commended to the profession as a credit
to American medical literature. The publishers deserve special prai>e
for the elegance of the typography and the care taken to produce the
colored plates with the most artistic results. J. N. H.

Kiinik dkr Verdauungskrankheitex. Von Dr. C. Ewald, Professor

e. o. an der Univereitiit, dirigirender Arzt am Augusta Hospital zu Berlin.

II. Die Krankheiten it- M auens. Berlin, August Hinchwald, 1888.

-Es op Digestion. By Dr. C. Ewald. II. The Diseases of the

Stomach.

This work occupies the middle space in a series of three of which the
first, the Physiology of Digestion, has already appeared, while the last,

> TralU do* Maladle* de It Peau, p«ur M. Rayer, etc. Pari*, 1835.

» Ikunojrraphe* Daratellung der nlcht-«yphilltl»chen Hautkrankhelten, mlt darauf be*Uglichen
timtmm T.-xtr, uuter Mitwirkungde* Herr Oebelmrath Dr. TrUttedt und Dr. Fred. Jakob
Bohreud, Lelptlg, 1839.

EWALD, DISEASES OF DIGESTION. 497

the Diseases of tht . is, as yet, in embryo. It consists of twelve

lectures occupying 431 octavo pages, to which the term "practical" is
peculiarly applicable. Beginning with a description of the mechanical
measures employed to obtain a sample of the stomach contents, the
author next describes their chemical investigation. The former are so
well known as to render unnecessary their detached description, but it
is important to observe that Ewald deprecates the employment of
suction, whether by rubber bag or piston, for the purpose of drawing
the stomach contents into the tube. Observing that during the act of
coughing they are ejected through a tube introduced into the viscus, he
was led to employ abdominal pressure with the object of obtaining the
requisite sample, and found it amply sufficient.

To obtain accurate results the examination of the gastric secretions
should always be made under precisely similar conditions. This rule,
which would appear to be self-evident, has not always been observed,
and to this oversight are to be described the discrepant statements of
various investigators. Ewald's plan is to administer to the fasting
patient a test-meal (Probefruhstiick) composed of a certain quantity of
white bread (Semmel) and water, or weak tea. Such a meal contains
albumin, sugar, starch, fat, salts, and extractives, and is very soon re-
duced to a fluid or semi-fluid condition, so that a portion of it may be
readily withdrawn by the stomach tube. In so far as its acidity is con-
cerned, the normal digestion of this test-meal may be divided into three
stages. A few minutes (ten to fifteen) after its ingestion it is acid, this
reaction, which continues about three-quarters of an hour, being due to
lactic acid. Then begins a stage in which, together with lactic, hydro-
chloric acid may be detected. Finally, the lactic acid disappears and
normally after the lapse of an hour only hydrochloric acid is found. It
has been supposed that the presence of organic, especially lactic, acid in
the stomach was always pathological, but late researches, especially
those of Ewald and Boas, have shown that, in the first stages of diges-
tion, an organic acid is always present, but the presence of such acids
in a late stage of the process is thought to be of pathological import.

Our author gives a list of the various tests, mostly aniline dyes, em-

E loved to detect the presence of free hydrochloric acid in the stomach,
ut believes they are all thrown in the shade by the recently discovered
phlorogluein-vanillin test of Giinzburg. A full description of this, one
of the most important tests employed in clinical medicine, may be
found in the Medical Xetvs of January 14, 1888.

It is an interesting fact, pointed out by Ewald, that Golding Bird, in
1842, was the first to examine the contents of the stomach in a case of
pyloric cancer with dilatation, with a view to determine the presence or
absence of free hydrochloric acid. He found the free acid present in
considerable quantity " during the more irritative stage of the disease,"
and. as the strength of the patient diminished, it gradually decreased,
while, in corresponding proportion, the inorganic acids increased. Bird's
researches seem to have been entirely overlooked by his countrymen.

The frequent absence of hydrochloric acid from the gastric secretions,
in cases of cancer of the stomach, is believed by Ewald to be due, not
to any mystical influence exerted by carcinoma upon the production of
this acid, but simply to concomitant inflammation or atrophy of the
gastric tubules. An interesting case of pyloric cancer is reported, in
which, during life, free hydrochloric acid was constantly found in the

498 REVIEWS.

stomach contents. At the autopsy the cancer was found to be strictly
localized, and the raucous membrane for the most part intact. The
views of Ewald, with reference to the diagnostic value of the absence
of hydrochloric acid in cases of gastric cancer, may be summarized in
the following words : As a rule, there is no free hydrochloric acid in a
cancerous stomach. Unfortunately, the value of this negative diag-
nostic sign is impaired by the fact that free hydrochloric acid is absent
in certain other affections, such as atrophy of the stomach, amyloid de-

feneration, and mucous catarrh. On the other hand, the presence of
ydrochloric acid is strong evidence against the existence of gastric
cancer, for cases, such as the one just referred to, are so rare as to be of
little diagnostic weight.

The fact that carcinoma of the stomach may be simulated by grave
forms of hysteria, is emphasized and illustrated by reports of cases. It
seems, says the author, scarcely possible to confound the two conditious,
and yet cases are encountered in which, after long observation, the diag-
nosis is uncertain. Hysterical cases have even been encountered in
which, with all the subjective symptoms of gastric cancer, there has
eventually appeared an apparently pathognomonic tumor, said tumor
being composed of the patient's own hair which she has swallowed.

The compensatory power possessed by the different sections of the
digestive tract is dwelt upon and well illustrated by reference to a case
under observation for three years, in which, although the patient con-
tinued to enjoy fair health, repeated examinations of the stomach con-
tents demonstrated the absence both of pepsin and hydrochloric acid.
The important part assigned by nature to intestinal digestion, coupled
with the fact that it may entirely supplement the action of the stomach,
has led Jaworski to attribute a subordinate role to the stomach, which
he regards as a species of warm chamber, in which the food is detained
for a time prior to its delivery to the intestine. This view reminds one
of the Hippocratic theory of the coction of food by animal heat.

In non-dilatable strictures of the oesophagus gastrostomy is urgently
recommended as the only means of preventing death from starvation.
The operation is, in itself, attended with little danger, and patients
seldom refuse to submit to it. Out of five to whom it was recommended
by Ewald, only one declined to undergo it, and he was a Russian
general who preferred death at St. Petersburg to a surgical operation in
Berlin. Detailed directions concerning the operation are added by
Sonnenburg. Minute details are given with reference to the diet of the
gastrostomized patient. After gastrostomy, although the obstacle to the
introduction of food is surmounted, the dilatation of the oesophagus
remains and constitutes a species of incubator, in which saliva and
mucus undergo decomposition, which is manifested by fetor of the breath
and the regurgitation of fetid fluid. Under such circumstances the
oesophagus must be washed out by means of a tube through which are
passed solutions of salicylic Mia, thymol, resorcin, borax, etc. The
same substances may be swallowed, and Ewald has also prescribed small
• Hiantities of brandy, of which the alcohol is an excellent disinfectant.

The important subject of dilatation of the stomach is considered
under the head of stenosis and stricture of the pylorus, although, it is
scarcely necessary to say, the author divided cases of dilatation into two
groups: 1st, those caused by mechanical obstruction; 2d, those din to

EWALD, DISEASES OF DIGESTION. 499

— thenia, or akinema of the stomach, a condition liable to arise in the
course of anainia, various nervous affections, exhausting acute and
chronic di.-eases, etc. In the treatment of dilatation, as adjuvants to
lavage, upon which, of course, great stress is laid, massage and faradiza-
tion are recommended. Until recent times there was no certain means
determining whether or not faradization of the abdominal walls gave
to contraction of the stomach. In a case reported by Pepper
Philadelphia Medical Time*, May, 1871), to which reference is made, the
contractions of the stomach which were distinctly visible, could not be
excited by faradization — i. e., visibly excited. At the present day, by
the use of salol, we have a more certain test of the motility of the
stomach. This substance, a combination of phenol and salicylic acid,
remains unaltered in the acid secretions of the stomach, but no sooner
does it enter the duodenum than it is decomposed and salicylic acid
appears in the urine. Under normal circumstances, salicylic acid may
be detected in the urine in from forty to sixty minutes after the inges-
tion of one gramme (fifteen grains) of salol. By means of this ingenious
test, Ewald and Sievers have been able to demonstrate that the passage
of the stomach contents into the duodenum is hastened by the applica-
tion of electricity to the abdominal walls. Contractions would, doubt-
less, be more certainly excited by passing one of the electrodes into the
stomach and placing the other upon the abdominal walls, or within the
rectum, so that the whole intestinal tract would be traversed by the
current.

Ewald believes that much is to be hoped from surgery in the treat-
ment of stomach diseases. He refers to the forcible dilatation of the
pylorus, in cicatricial contraction, twice successfully performed by
Loreta, of Bologna, and thinks it probable that, in cases of dilatation,
a piece of the organ might be excised with benefit.

With reference to the value of statistics as to the frequency of this
or that symptom in cases of cancer of the stomach, his remarks are
generally applicable to all similar arithmetical work. " Even sup-
posing," says he, " that we have the figures in mind, who will assure us
that the case before us is one that comes under the rule, and not an
exception ? "

The foregoing remarks will serve to give an idea of the scope of
this excellent work. The prevailing impression, after the reading of
each lecture, is that the subject has been handled in the most skilful
manner. The style is clear and terse, and typographical errors are
remarkably few. The only ones noticed were in a footnote on page 179,
where occurs the following obscure reference to a case reported by
Btorer of Boston: "Colloid disease of the entire stomach with wery
utoms." Again, on page 83, a catheter a demeure is spoken of.
The word should be demeure, without any accent.

The quotation with which the work concludes expresses most happily
the spirit which animates its every page —

" Uti ratio sine experiments mendax,
Ita experientia sine ratione fallox."

F. P. H.

500 REVIEWS.

Anesthetics, their Uses and Administration. By Dudley Wilmot
Buxton, M.D., B.S., Member of the Royal College of Physicians ; Member
of the Royal College of Surgeons of England ; Administrator of Anaesthetics
in University College Hospital, the Hospital for Women, Soho Square, and
the Dental Hospital of London. 12mo. pp. xii. 164. London : H. K.
Lewis, 1888.

A good manual of anaesthetics, a treatise at once concise, precise, and
practical, would be a welcome addition to medical literature and an
especial boon to the student. In the effort to supply such a work the
author of this little book has been tolerably successful. It is written
from the standpoint of practical life, under a strong feeling that the
administration of anaesthetics deserves more attention and study than it
receives, and that for satisfactory use of these agents both knowledge
and skill are necessary. It is scientific in spirit and scrupulously non-
partisan. Still, with very much for commendation, there are features
which might have been better. Nitrous oxide occupies as much space
as chloroform and more than ether. The chapter on the less-used aim s-
thetics might well have been omitted ; amylene belongs to the past, and
the record of ethylene is not such as to encourage further trial. To say
the same of bromide of ethyl would probably arouse dissent here, and it
is mentioned only to call attention to the fact that the author has
omitted any notice of the marked perturbative influence of this agent
upon the heart's action. But the gravest fault to be found with the
book is precisely one which would not be expected from the opportuni-
ties enjoyed by the author, as set forth in the title page, for practical
acquaintance with his subject. Instead of that honest dogmatism which
comes from experience and which is so valuable in a teacher, we have
too frequently the indefiniteness of general statement, or the preface of
" some find " things thus and so, or " it is said " that such a thing " may
be tried." This in connection with some of the most important points
relating to the subject is a grave fault. As an instance the following
may be given :

" Where the kidneys are much damaged and there is considerable danger
of suppression of urine, ether is by many held to be contraindicated. I
tninly in many instances no such untoward result has been brought about ;
still, perhaps, it is well to substitute the A.-C.-E. mixture for ether, for those
patients who are the subjects of renal disease."

In this country the doctrine that disease of the kidneys is a contra-
indication to thi' administration of ether, first taught by Emmet, is, we
believe, fully accepted, nor is it considered necessary that these organs
be "much damaged." The student would perhaps like to know how he
is to recognize the presence of danger of suppression of the urine.

Many instances of indefinite statement could be selected, but it is a
pleasanter task to note points for commendation. In the choice of an
anaesthetic the author considers: 1, the condition of the patient ; 2, the
necessities of the operation. In the chapter on ether, eight comlin
are given in which this agent should not be used. We find no dedded
expression in favor of or against cither of the individual ana .-thctics,

it it is easy to read between the lines that chloroform is not a favorite.

t is a significant fact that it is not mentioned as a substitute in the

BUXTON, ANAESTHETICS. 501

quotation already made. So, also, is the statement that the men who
have bad most to do with chloroform have been occupied in trying to
find some substitute for it. Snow introduced amylene and tried ethy-
lene, and Clover devised the combination of nitrous oxide followed by
ether, doubtless the safest anaesthetic process, but requiring complicated
apparatus, and, therefore, not adapted to private practice. No exception
can be taken to the statement that anaesthetics stand, as to relative
mortality, in the order — nitrous oxide, ether, chloroform ; but the figures
to support this statement might have been spared. There is, and can
be, no statistical basis of relative mortality because the number of
administrations cannot be obtained. The friends of chloroform will be
encouraged by the statement here made that there have been 36,500
administrations of this agent at the Edinburgh Infirmary during ten
years, with hut one death.

We are glad to find here the table, from Snow, showing the different
percentages of chloroform vapor in air at different temperatures, a point
often overlooked by writers, but which should never escape the attention
of the administrator. At 60° F. air carries twelve per cent, of chloro-
form ; at 80° twenty-six per cent., or more than double, and a range of
temperature over these points occurs from season to season, and may
occur even from day to day.

With the author's doubt as to there being any special immunity from
disaster with chloroform on the part of children, we are fully in accord.
Elements of safety there are in this class of subjects, but absolute safety,
although often taught, is not supported by facts, and while we admit,
witli him, that children run a risk with chloroform are not prepared to
accept the view that it is "probably as great" as with adults. One of
the leading journals of this country contains, within the present year,
two reports of the narrow escape of children from chloroform narcosi>.

Especially worthy of praise is the plainness with which the danger of
partial anaesthesia is presented. Having been an urgent advocate of
this danger, many years before it was recognized, as it now is, by the
best authorities, we still frequently see the necessity of its promulgation
in directions to operate during the early stage of anaesthesia, "after
a few whiffs " of the agent. As the author well says, " nothing can be
more prone to produce fatal syncope." Indeed, the plain truth is here
fully recognized that by partial anaesthesia danger is increased.

"Under these circumstances, too, it must be remembered that the
heart is peculiarly liable to reflex inhibition, as vaso-motor paralysis
occurs antecedently to loss of conduction along the sensory tracts of the
nerves and cord."

In regard to death from anaesthetics, most important is the distinct
recognition of the facts that it sometimes takes place under ether by
failure of the heart's action being the first step, and under chloroform
by cessation of respiration. Instances of each are on record, yet the
lethal action of ether on the heart has been strenuously denied. The
subject of death from chloroform is not as satisfactorily presented as it
deserves. The one great fact of irregularity of action of this agent is
not emphasized as it should be. The amount in the blood is not the
only point; it kills sometimes at the very beginning of inhalation; it
pmves suddenly fatal to those who have taken it safely before.

Having used the A.-C.-E. mixture almost exclusively for surgical anaes-
thesia ever since it was first recommended to the profession — now twenty-

VOL. 96, NO. 5.— NOVEMBER, 1888. 33

502 REVIEWS.

five years ago, we looked over the chapter on " anaesthetic mixtures "
with unusual interest. It does not bear that evidence of practical
acquaintance with this branch of the subject which gives value to what
the author has to say. It is stated that the A.-C.-E. mixture " needs care-
ful watching;" and we ask if it is herein different from any other anaes-
thetic? It is also stated that deaths have occurred during its use, but
facts to support the statement, or references to authorities are lacking.
A careful scrutiny of periodical and other literature has yielded but a
single fatal casualty with this mixture.1 It is with regret that we find
repeated here the objection to this mixture based on the different rates
of evaporation of its three components. This is a laboratory objection
transferred to the clinical field and will not bear examination.

Mixed narcosis, as produced by the combined effect of morphia and
chloroform, is mildly endorsed, and the addition of atropia to the
morphia given hypodermatically before the inhalation, is very justly con-
sidered of great value. The author gives Kappeler's adverse opinion
as to the combined effect of ether with morphia, and expresses doubts
of its sound clinical basis. " Certainly in cases at University College
Hospital in which the method was employed no great struggling or
inconvenience was observed." A very considerable experience with the
combination of morphia and atropia preceding the A.-C.-E. mixture,
which is half ether, has failed to give any evidence of the correctness of
Kappeler's views upon this point.

The chapter on anaesthetics in obstetric practice is very brief and, we
regret to say, not worthy of the important subject considered. We refer
to it only for one or two points. On page 19 the author says " chloro-
form can be in no way deemed freer from liability to danger in child-
birth than at any other time." On page 111, considering the objection
that this agent increases the mortality of mothers and children, he says,
"statistics certainly negative this statement." The author may recon-
cile the statements. The truth is, that the clinical experience of the
world has shown a wonderful immunity to accidents from chloroform on
the part of the parturient woman. So marked has this been that
numerous and ingenious theories have been devised to explain the strik-
ing but happy fact. We wish the author had told us in this chapter
why, " in primiparse, chloroform must be given very moderately."

We trust that a new edition of this little work will be prepared, which,
abbreviated in some portions and extended in others, will make an
excellent manual for the student. J. C. R.

I\i i: \< JB \M ai. TUMORS. By BKYOM BbAXWBLL, M.D.. Lecturer OB the
Principles ami Practice of Medicine in the Kxtra- Academical School of
Medicine, Edinburgh. With 116 illustrations. 8vo. pp. xiv. 270. Phila-
delphia: .1. B. Lippincott Co.. 1888.

It is always interesting to read a work based upon the careful clinical

and pathological obeervatfona of a man of wide experience, for it. is sun'

aiu original views and to form an addition to the knowledge of

» Reported by Dr. Morton, Amu. J ovum. Mid. 8cimcm, October, 1876, p. 416.

BRAMWELL, INTRACRANIAL TUMORS. 503

the subject treated. Dr. Bramwell has chosen a Bubject of special
importance at the present time when the claims of cerebral surgery in
the treatment of intracranial tumors are being urged and discussed,
and as tliis is the only monograph in English upon the subject it will
be widely read.

The first half of the book is devoted to the symptomatology of brain
tumors in general. Clinically cases may be divided into four classes:
(1) those in which no symptoms are present ; (2) those in which gen-
eral symptoms of an intracranial tumor are found but in which there
are no symptom*! indicated of its exact site; (3) those in which the
symptoms indicate not only a tumor but its exact location ; (4) those in
which there are distinct indications of derangement or disease of the
intracranial contents, and in which the symptoms may be due to the
presence of an intracranial tumor but are not typical and characteristic
of that condition. Each of the distinguishing general symptoms of
brain tumors is carefully discussed, viz., headache, vertigo, vomiting, and
double optic neuritis. In regard to the last, the author holds that the
affection is not always produced in the same manner. He admits the
possibility of a descending neuritis, but inclines very strongly to the
Leber-Deutschmaiw: theory that increased intracranial pressure com-
bined with some irritating substance in the cerebro-spinal fluid sets up
the neuritis, though he admits the hypothetical nature of this substance.
The chapter on optic neuritis presents the subject clearly and states
concisely the various theories as to its cause. The localizing symptoms
are then detailed briefly but clearly, the chief facts being stated and
fuller discussion postponed to the section in which the diagnosis of the
localization of the tumor is treated. In this section some of the most
recent discoveries seem to have been overlooked — e. g., the discovery that
the cuneus is the visual centre, but as the book is based on lectures
delivered a year ago this is not surprising, for progress in cerebral diag-
nosis is very rapid.

The chapters on differential diagnosis are well written. Three ques-
tions are considered separately : 1. Is there an intracranial tumor? 2.
■, where is it situated ? 3. What is its pathological nature? Under
the first question the differentiation of Bright's disease, lead encephalo-
pathy, hypermetropia with anaemia, atrophy of the brain, migraine,
hysteria, meningitis, cerebral abscess, and hemorrhage from cerebral
tumor are carefully discussed, and some difficulties cleared up. The only
criticism which may here be offered is that in some cases two or more
of these conditions are present, as well as cerebral tumor, and in such
cases diagnosis becomes very difficult. This section, however, will be of
ice to the general practitioner as well as to the neurologist, as it is a
suggestive one.

In considering the second question, the subject of cerebral localization
is presented concisely, due importance being given to the necessity of
separating direct local symptoms from indirect or pseudo-localizing
symptoms produced by disturbances of circulation or function at a dis-
tance from the actual seat of the disease. The symptoms produced by
tumors situated in various portions of the brain are then discussed.
By this arrangement repetition is inevitable and constant cross references
between the chapter on the localizing symptoms and this chapter are
necessary and it seems unfortunate that the two should not have been
combined into one. The third question as to the pathological nature

r>04 REVIEWS.

of the tumor, is carefully considered and all the indications which can
throw light on this very obscure field of diagnosis are given. The last
chapter is devoted to the surgical treatment of intracranial tumors and
is written by Mr. A. W. Hare. This is decidedly meagre, but nine
pages being given up to it and many important details being entirely
omitted. This is especially unfortunate, as it is the practical side of the
subject that at present excites much interest.

The work then presents in an acceptable manner — exclusive of the
last chapter — the important subject with which it deals, and is a
valuable contribution to medical literature. The only criticism which
may be offered is that the author has not embodied in it the results of
other observers, notably Bernhardt and the German writers and there-
fore the work is less complete than might have been expected from his
previous writings. M. A. S.

Intubation of the Larynx. By F. E. Waxham, M.D. 12mo. pp. 110.
Illustrated. Chicago: Charles Truax, 1888.

This little volume is a detailed exposition of the very important
procedure which Prof. Waxham has done so much to popularize. It is
appropriately dedicated to Dr. O'Dwyer, whose name will be prominent
in the history of medicine in connection with intubation of the larynx.

One hundred and fifty cases of intubation by the author for diphtheria
are narrated with sufficient detail for due appreciation of their import ;
and a table of one hundred cases by Dr. O'Dwyer is appended. Of the
150 cases intubated by Waxham 41 recovered, and of the 100 by O' I hvver
27 recovered ; a striking similarity in result. It is pleasant to learn that
the proportion of recoveries at a tender age far exceeds that which fol-
lows tracheotomy. Every detail necessary in studying and practising
this important manipulatory procedure is duly presented in Prof. Wax-
ham's manual, and is admirably illustrated. We are pleased to see that
the author advises the precautionary use of an antiseptic respirator by
the operator during his manoeuvres.

By means of an artificial epiglottis attached to the tube the author
has been able in some instances to overcome the difficulty in swallowing
water and liquid nourishment which has been such an obstacle in the
after-treatment. We would call especial attention to the advice of the
author that great care should be taken to see that all the appliances used
are carefully constructed, in order that unnecessary disappointments and
accidents may not follow their use.

We earnestly recommend all physicians who intend to practise intuba-
tion to study this working manual of Pro£ Waxham, as their best method
of avoiding much unsatisfactory experience inseparable from practising
a novel operation under such important conditions as those calling for
intubation of the larynx. Intubation, while it is not expected to super-
sede tracheotomy in all instances, will save many a sufferer from an
Otherwise inevitable tracheotomy, and save from death many more in
WbOM behalf tracheotomy is refused, or whose surroundings are such as
leny them the subsequent supervision necessary to secure all the ad-

NATIONAL FORMULARY. 505

vantages <•!' that operation. If ovariotomy has added its thousands of
ri to the lives of dying women, shall not intubation add its tens of
thousand* to the lives of dying children? J. S. C.

Thk National Formulary of Uxofficinal Preparations. First
Issue, by Authority of the American Pharmaceutical Association, 1888.

The wisdom of having this work, somewhat similar in its scope to
the Pharmacopoeia, published without the official sanction of the medical
profession may well be challenged.

On looking through the book the elixirs — eighty -five in number — are
found to be quite conspicuous. One aim has obviously been to make
the administration of drugs more attractive to the eye and palate of the
patient ; quite a praiseworthy object, but not the only, nor the chief one,
to be kept in view in giving medicines.

loubt, many practitioners are in the habit of prescribing this or
that elixir or mixture made by various firms, and it is a hardship for
the apothecary to be obliged to keep on his shelves essentially the same
preparation made by several manufacturers, and the general use by
physicians of such a volume as this would relieve the pharmacist from
much of this burden.

The following examples, which are already much used (are taken
from the Formulary), would make an excellent addition to our officinal
list of drugs : Chloroform water ; glycerite of tannic acid; camphorated
chloral ; Fehling's solution ; pancreatine ; solution of pancreatine ; and
solution of saccharin. To these might well have been added pills of
quinine, as they were not provided for in the last Pharmacopoeia.

Fleming's tincture of aconite, a stronger preparation than the officinal
tincture of this very poisonous drug, is to be found in this list; ev< -ry
precaution should be- taken not to confound these preparations with
each other.

The composition of compound powder of pepsin is open to criticism
from a physiological standpoint, as it is made up of diastase, pepsin and
pancreatine with hydrochloric and lactic acids and sugar of milk.

The prescriptions for newer remedies have not been included, but it is
intended to put them in a second edition of the work, should there be
occasion for its publication. This list cannot replace the officinal one,
and the addition of more than four hundred titles (the Pharmacopoeia
has about one thousand), would increase, in some ways, the embarrass-
ment which the practitioner has to encounter.

The problem of how best to assist the physician in the intelligent use
of medicines has been considered by a committee made up of representa-
tive physicians and pharmacists, and the outcome of their labors, the
Un Pharmacopoeia, is more or less familiar to the great body

of practitioners. The last revision of the Pharmacopoeia is by no means
perfect, and the time for the next revision being near at hand, this
Formulary will, doubtless, afford useful hints to the new committee, and,
perhaps, promote some provision for the issue of a supplement after five
years.

506 REVIEWS.

It is to be hoped that the revision of 1890 will give the country a
work much superior to anything thus far published, and that it will not
he thought necessary for the American Pharmaceutical Association to
set up a " standard and guide," including " catarrh powder " and " diar-
rhoea mixtures."

The united efforts of both physicians and pharmacists should be
directed toward making the best and simplest pharmacopoeia, which shall
he in universal use by American physicians. F. H. W.

The Anatomy of Surgery. By John M'Lachlan, M.B., M.R.C.S.,
Master of Surgery, University of Edinburgh. Illustrated with 74 engrav-
ings. 12mo. pp. xv. 768. Edinburgh : E. & S. Livingstone, 1887.

The fact of this book having been written for the special purpose of
supplying aspirants for medical degrees in Great Britain with the mate-
rial with which they are expected to be familiar in order to attain the
highest of these degrees, at once bars much criticism which would be
applicable to a similar treatise intended for the profession and students
in general ; but evidently the writer and his publishers, upon comple-
tion of the work, have thought it sufficiently valuable to place upon
general sale. Very probably the contained history, etiology, clarifica-
tion, symptomatology, diagnosis, and treatment of the usual conventional
surgical operations and procedures concord exactly with the ideas of the
British Board of Examiners, so that any criticism would be of the ideas
of that board and not of the book itself. Considering the book upon its
literary merits and its value to the American student and practitioner,
we find in it some points of advantage over other operative surgeries or
surgical anatomies, and also many in which it falls short of being best
amongst such works.

The author's prefatory statement that the book will not be found
complete is verified by its perusal, but his excuse therefor and for errors,
on the ground that the volume " has been very hurriedly put together,"
is far from being valid or sufficient. The usual idea and plan of similar
uniks form the hasis of the one in hand, and the customary chapters on
ligations, amputations, etc., are in it to be found : but symptomatology,
etiology, classification, and diagnosis receive better and more lengthy
consideration than is usually allotted to them. Fractures and disloca-
tions receive separate chapters ; the anatomy of which is excellent, but,
as might be expected, treatment at times differs widely from that in
vogue in America. The illustrations are not sufficiently numerous,
and some are exceedingly poor. The inclusion of a number of Smith
and Walsham's beautiful plates of the collateral circulation of the main
arteries is a valuable addition to the book's worth, as also is a table
ihowing the origin, attachment, and nervous supply of every important
muscle. Whilst we are bound to acknowledge many good points in this
k'l favor, yet are we equally bound to say that we would neither add
it to our library, nor direct its use, above others, by a medical class.

PROGRESS

MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

FRANCIS H. WILLIAMS, M.D.,

ASSISTANT PROFESSOR Or MATERIA MED1CA AND THERAPEUTIC* IX HARTARD FNIVERSITT.

Phenacetin.

Of the many reports on the use of phenacetin, or acetphenetidin, one
recently made by Dr. Friedrich Muller [Therapeutische Monatshefte,
August, 1888) is of unusual merit. He made numerous trials of the remedy
in various diseases, and found that the temperature in adults was lowered by
doses of from seven to eleven grains, and seldom as much as fifteen grains
was used. The fall in the temperature occurred within from one to four
hours, and was accompanied in most cases with perspiration, but without dis-
agreeable sensations.

During the apyrexia, which lasted from three to five hours, the patients
were quite comfortable, having a better appetite and more sleep. The rise in
temperature was unaccompanied by a chill. For the patient's comfort it is
desirable to avoid alternate fall and rise in the temperature. If the drug is
administered continuously, the temperature rises in spite of it, and after some
days the system becomes habituated to the agent, and larger and larger doses
are required — in fact, so large as possibly to become dangerous. He has
observed marked cyanosis from 90 to 120 grains daily.

Nothing more is accomplished by phenacetin than by the other antipyretics,
for example, antipyrin ; but it has the advantage of less unpleasant accompani-
ments. It is tasteless, vomiting and indigestion appear only exceptionally,
ringing in the ears, or exanthematous eruptions, or signs of renal irritation
were not observed. In some cases phenacetin seemed to promote diarrhoea.

Like some other antipyretic agents, phenacetin possesses the property of
quieting pain, and has been employed to relieve headache, except that con-
nected with organic cerebral disease, or uraemia. For this purpose forty-five,
or even seventy-five, grains a day are required. In some neuralgic affections
the pain is relieved by phenacetin, and for such purposes it seems to be in no
wise inferior to antipyrin and antifebrin.

508 PROGRESS OF MEDICAL SCIENCE.

In twenty-four cases of acute articular rheumatism, prompt relief from
fever and the pain and swelling in the parts was obtained in fifteen cases,
and disappeared wholly in from two to nine days, in four cases no improve-
ment followed, and in six the condition was not affected. Of these six, two
were of gonorrheal origin, and two were considered cases of chronic rheu-
matism.

Phenacetin, it would seem, deserves to be placed in the same rank with
antipyrin and antifebrin as an antipyretic, and also as a means of relief in
rheumatism and neuralgic pains. It is interesting to note that phenacetin
possesses practically no antiseptic qualities.

Cocaine.

Any observations which will suggest the limits of safe doses for cocaine
have a very practical interest. Dr. Szumann, in the Therapeutische Monats-
hcfte, suggests, for adults, one-half, or three-fourths, to one grain, subcutane-
ously. With such doses he saw no untoward effects; one grain, however, is
adapted only to robust individuals. Some patients will, of course, bear very
large doses, among them certain opium-takers, who have used as much as
seven to thirty-seven grains daily, though one may get toxic symptoms in such
patients from an injection of one and a quarter grains.

With nervous patients, and also with those having cardiac disease, as well
as those inclined to cerebral congestion, large doses of cocaine may prove
dangerous on account of the marked effect on the heart and circulation, as
Alexander Frankel has very properly emphasized.

Cocaine in General Anaesthesia.

This method varies from that mentioned in the September number of this
Journal (page 288), in that the cocaine is injected for its local anaesthetic
effect at the seat of operation, after the general anaesthesia has been induced*
Though both substances are administered for the same end, their combined
use, according to Prof. Oblinski, excludes certain dangers of the separate
employment of each. In cocaine we possess an excitant which is the best
possible antidote to the action of chloroform in paralyzing heart and vessels.
So the use of chloroform is a good measure against the symptoms of brain
aim-mill that cocaine often produces. The amount of chloroform used is
less — vomiting occurs less often, and especially noteworthy is the gentle re-
covery.— Wien. med. WocJirnsrhrift, 1888, Nos. 15 and 16.

On the Administration of Sulphonal.

In the Therap. Monatthefte of July 2, 1888, Kast, the discoverer of sul-
phonal, gives some experimental conclusions directed to the point of the
Pttwded ariivity of sulphonal. From published papers (Cf. Lovegrove, Brit.
V / tmal, 1888, p. 1112) and private communications he has learned that
many have found that the primary hypnotic action is postponed too long —
i.e., two or three hours or more, and that the effect lasts longer than is wished
— i.e., into the succeeding day.
Two important qualities distinguish sulphonal, he observes: First, its in-

THERAPEUTICS. 509

solubility; second, its resistance to chemical change. Sulphonal i3 soluble,
he finds, by exact estimation in eighteen or twenty parts of boiling water, but
it rtcrystallizes on cooling. At blood-heat, 450 parts of water are necessary to
dissolve one part of sulphonal. Addition of salts considerably increases its
solubility — thus it is easily soluble in concentrated mineral water. The addi-
tion of an amount of hydrochloric acid, corresponding to the proportion in
the gastric juice, increases its solubility one-half. In artificial gastric juice
it is soluble 1 : 200, at the tempeiature of the body, and it was not reprecipi-
tated for several hours after neutralizing. Peptones prevented the repre-
cipitation of a very concentrated solution made in hot water.

As to the absorption, Kast found that very small quantities of sulphonal
were present in the intestine of a dog killed two hours after the ingestion.
After six hours none could be demonstrated in the gastro-intestinal tract, but
small quantities were found present in the blood.

These facts lead to the determination of the best method of administration.
This should be in a good quantity of warm water in the early evening hours,
and best with the supper. In this way advantage is taken of those conditions
favoring a rapid solution, viz., a fairly large quantity of water with a good
proportion of hydrochloric acid, and salts and peptones in rich abundance.

Method of Testing a Hypnotic.

As many physicians will undoubtedly be led to experiment with some of
the numerous new hypnotics, a mention of Rosenbach's cautions will certainly
be profitable. Recognizing the importance of the mental attitude of the
patient as a factor, he advises, first that the hypnotic be given without the
knowledge of the patient at times other than bedtime; second, if the results
appear good, that the patient be made acquainted with the experiment, and
then an indifferent substance be substituted, to be alternated now and then
with the hypnotic; and finally, it is to be given to patients, without their
knowledge, who are not in bed. — Berl. klin. Wochemchrift, 1888, No. 1\.

The Absorption of Cod-liver Oil— Lipanin.

Physiologists have always been at work upon the question, What makes
cod-liver ofl more digestible and assimilable than other oils and fats? The
explanation was in turn found in the iodine present, in its property of passing
through animal membranes more easily, and, finally, it was asserted that it
was no different from any other fat. Each of these views was in turn dis-
proven and gave place to that which has prevailed for a decade, since it was
first set forth by Buchheim. This finds the key in the larger proportion of
free fatty acids present, which assist in the emulsification of the fat after the
oil has reached the duodenum. In general, though, the proportion of free
acid in ol. morrhuse is very variable, and for this reason and because of the
di>agreeableness of the oil, Mering (Therap. Monatshefte, 1888, p. 49) had
made a substitute which has been put into the market under the name of
lipanin [Xarahu, to fatten). This consists of olive oil containing six per cent,
oleic acid, of pleasant taste and emulsifying very easily. Mering has used it
now in forty cases of rickets, phthisis, etc., and in all the effects on nutrition

510 PROGRESS OF MEDICAL SCIENCE.

was positive, the weight increasing. No symptoms were noted on the side of
the digestive tract. The dose is the same as for cod-liver oil.

Recently Marpmann, an apothecary in Miinchen, has taken up the subject
again and thrown new light upon it (Munch, med. Wochenachrift, July 7, 1888).

The digestion of fat is a subject about which we possess but little accurate
knowledge, but it seems improbable that the small quantity of fatty acid
present in cod-liver oil can be of so much importance when we consider that
neutral fats in food are perfectly well borne and assimilated, and that the
pancreatic juice has the power to split up a neutral fat into fatty acid and
glycerin. Marpmann, then, was not satisfied with the fatty acid theory, and
looking for another source finds it in the stomach, to which, before him, no
attention had been directed. Fat is better borne the more intimately it is
mixed with the food and saliva — ?'. c, the better it is prepared to pass
the stomach ; oil in any considerable quantity upsets the stomach, because
it envelops the food and prevents gastric digestion, and when one fat is found
better borne than another, the ground is to be sought in the way such a fat
behaves in the stomach.

Impelled by such considerations as these, Marpmann tested various oils with
artificial gastric juice. All the oils shaken with the gastric juice separated
immediately on standing, but cod-liver oil remained emulsified for fifteen min-
utes, and after twenty-four hours had cleared up only one-half. Here, then,
according to Marpmann, is the explanation of the superiority of cod-liver oil,
viz., that it passes out of the stomach and meets the pancreatic juice after it
it already in a finely divided state, while other oils, keeping their independent
existence in the stomach, enter the intestine in the form of large drops.

By the same experiment lipanin refuses to mix with the gastric juice, but
separates its oil quite pure after a few minutes; a mixture of olive oil and
phosphoric acid separates just as pure olive oil. These facts prove that the
miscibility of cod-liver oil with the gastric juice cannot depend upon its con-
taining free acid. On the other hand, first, fat-peptonate, another substitute
for cod-liver oil, consisting of cod-liver oil and olive oil mixed with pancreatic
juice, and, second, a mixture of olive oil and oleate of soda, mix, the first
completely, no oil separating in twenty-four hours, and the second about as
tu.l liver oil.

These facta allow us, Marpmann believes, to suppose that the active ingred-
ient in cod-liver oil is a small quantity of some salt of a fatty acid. Later
he has obtained from cod-liver oil, by ether and alcohol, a substance which,
dissolved in water, gives other fats the properties of cod-liver oil, and which
is likewise present in the pancreatic fluid.

One practical conclusion which Marpmann draws is that cod-liver oil should
l>e mixed with the food and prepared in the mouth, rather than drunken.

Boric Acid in Antisepsis.

In the ,l,nrn. denied. <U Pari*, 1887, vol. ii. p. 180, some notice was given a
substance called antil'ungine, which was shown to be borate of magnesia,
soluble in four parts of boiling water, and possessing in fifteen per cent, solu-
tion very energetic antiseptic and disinfecting properties. In the same journal
<>l JuK I ., lsss. directions are given for making a substance like this, and

THERAPEUTICS. 511

possessing its same qualities. Dissolve one part of calcined magnesia in
nty-tive parts of water on a water bath, and add boric acid to the point
of making the solution cloudy. Tin's will require 12.4 parts of boric acid.
After evaporation, the ground residue makes a white powder of sweet taste,
soluble in four parts of water, and the solution is strongly antiseptic. This
substance removes the disadvantage of boric acid in point of insolubility.

An i i-kptic Properties of Ammonia.

Gottbrecht (Deut. med. Woch., July 19, 1888) calls attention anew to the
antiseptic properties of ammonia. These were long ago discovered by Rich-
ardson, though but little has been thought of the fact. Gottbrecht finds that
a solution containing liquor ammonia; in proportion of 1 : 100, keeps meat
from decaying seven days, and in proportion of 2: 100, and 4: 100, two and a
half months : while meat kept over a year in 5 to 8 per cent, solutions. Cul-
tures of this last gave negative results. Like Richardson, so Gottbrecht finds
the source of this control in the strong reducing power of ammonia.

Saccharin as an Antiseptic.

M. < "N-tantine Paul finds that saccharin possesses marked antiseptic
powers. A 1 : 700 solution controls the development of the staphylococcus
pyogenes aureus, and because it prevents the development of all microbes
contained in the saliva, etc., and a 1 : 200 solution prevents ammoniacal
change in the urine, he recommends its use in solutions for lavage of the
stomach and bladder.

A 1 : .500 solution hinders in an appreciable manner the action of pepsin on
the white of egg, fibrin, etc., and of diastase on starch, but does not arrest
either action entirely. This may perhaps account for the digestive disturb-
ances referred to by M. Worms [ride September number, p. 287), because it
cannot be said to be in any way toxic, being eliminated entirely unchanged by
the urine. Another explanation might be found in the condition of the kid-
neys. Saccharin has been made the subject of much discussion in France, and
Girard, director of the municipal laboratory of Paris, demanded that its sale
be stopped because of its extensive and growing use in adulteration of syrups,
liquors, and food. Under the name of sucre de Cologne it has been sold at a
low rate (four cents a German pound), and there is, besides, no duty op it —
Gomptc* rend, de Farad, de med., July 13, 1888, and Gaz. Hebdom., August 3, 1888.

Iodoform in H.«mopty-i~.

< HAtvix and Joi:: ., May 19, 1888, p. 387) have found

the best comparative results in the treatment of haemoptysis from the use of
iodoform, gr. j, in pill, twice a day. Their observations rest on a large series
of cases, and, therefore, are worthy of attention.

Diuretic Action of Strophanthus.

Lkmoine finds polyuria the most constant of the effects of strophanthus.
Experiments on healthy persons with gtt. 5-6 of tincture gave double the

512 PROGRESS OF MEDICAL SCIENCE.

quantiy of urine in forty-eight hours. The same success was obtained in
cardiac cases ; as a rule, the persistence of the diuresis was marked. A secre-
tion of 3 xiij was increased to three quarts, and five days after suspending its
use was still two quarts. In three cases a very abundant serous diarrhoea was
caused, only to be controlled by stopping the drug.— Comptes rend, de Soc. d.
Bio/., June 15, 1888.

SlMDLO A8 AN ANTIEPILEPTIC AND ANTIHYSTERIC.

Eulenburg (Therapeutmhe Monaishefte, 1888, 353) has made trial of the
tincture of simulo, prepared from the fruit of Capparis corriacea recently
recommended for the treatment of epilepsy by W. Hale White in the Lancet
of March 31st. He administered it during a long period of time to four cases
of epilepsy and three of grave hysteria. The dose employed was one-half to
two teaspoonfuls two or three times a day. In the hysterical cases it proved
absolutely useless, even as a palliative. The bromides, properly administered,
have proved themselves the best means we possess in the treatment of epilepsy.
There are cases, however, in which, through some idiosyncrasy, they produce
maniacal excitement, convulsions, or delirium ; though these are rare ; others
in which their action is too depressant to allow of their continuance, and still
others in which they exert only a partial control over the frequency and inten-
sity of the paroxysms. It was to be hoped that simulo might prove of value
as a substitute in such cases, but in only one of the four in which trial of it
was made, were the results sufficiently encouraging to warrant further experi-
ment with it. This case was that of a man of eighteen years, who for seven
years had suffered from frequent well-marked attacks of epilepsy, and in whom
improvement up to a certain extent had followed the use of the bromides.
During five months he was given the bromides for one to two weeks, and then
the tincture of simulo for an equal time. It was always the case at first that the
attacks were less frequent, and the patient felt better during the time that the
simulo was being administered ; but finally the drug seemed to lose its power
and had to be suspended, since the paroxysms grew more frequent. In the
other three cases of epilepsy the action of the new drug was evidently weaker
and more uncertain than that of the bromides in moderate doses.

Codeine and Morphine in Diabetes.

Dr. Mitchell Bruce has compared the effects of these alkaloids in two
classical cases of diabetes. The observations extended over several months.
and were made with great care. The sugar in the urine was first reduced to
a minimum by a strictly antidiabetic diet, and then one of the drugs was
administered to both patients, and its effects on the sugar were noted. Phos-
phate of codeine was given hypodermatically, and the dose was gradually
increased to more than twenty grains a day. After an interval on strict diet,
acetate of morphine was given to both patients, up to as high as five or six
grains per diem. Of the two drugs, the morphine proved to be the more effi-
cacious, as under it the sugar was more completely controlled. Codeine is
much more expensive than morphine, and large doses of it are necessary.
Narcotic effect* from morphine seldom presented themselves so long as the
sugar continued to fall.

THERAPEUTICS. 513

Dr. Bruce found some difficulty in removing the last traces of sugar, and
iggested that in practice we should be satisfied with reducing the sugar
to a small amount, rather than use the large doses required to free the urine
from it completely.

The full report of this carefully conducted inquiry may be found in The
Practitioner for July.

Glycerite of Starch as a Surgical Dressing.

Charles E. Fleming, M.R.C.S. (British Medical Journal, September 22d),
has found a non-irritating dressing which does not evaporate at ordinary
temperatures, does not allow the discharges to get caked or hard, while it is
freely miscible with them. It may have some antiseptic dissolved in it.
The starch added to the glycerine makes it more convenient to apply, and,
in addition, forms a non-irritating surface to apply to the wound, and is a
mechanical protection.

It is most conveniently used, thickly spread on one or more layers of
Gamgee tissue, or some absorbent wool ; it may be removed with the greatest
ease from any wounded surface. The glycerine itself is hygroscopic, does not
usurp the place of the discharge, nor prevent the free escape of watery vapors.
.Such a dressing, after several days, will be found moist, soft, flexible, and
heavy with the quantity of fluid it contains. Next the wound there is a jelly-
like layer, which may be removed readily, and the sutures, if any, are dis-
tinctly seen and easily taken out. Its use in skin-grafting is suggested.

Menthol in Pruritus Larii.

The application is made by rubbing the affected surface two or three times
with solid menthol ; it produces some burning pain at first, but is followed by
a most comfortable sense of coolness, and the congested color of the vulva
almost disappears. — British Medical Journal, September 1, 1888.

Creolin.

Amon, as well as other writers in the surgical field, has used creolin with
satisfactory success in obstetrics and skin diseases; he also obtained good
results in tuberculosis.

In pulmonary tuberculosis, and other allied diseases, accompanied with
more or leas secretion, he used creolin inhalations, and found that they were
inhaled easily and without harm. He began with one-half per cent, solu-
tions and increased them to two per cent. The inhalations had a favorable
effect upon the expectoration, and in almost every case the amount of the
secretion decreased perceptibly, and after some days the patients felt relieved,
fleet upon the course of the fever was observed. In cases in which there
were bad smelling excretions, they either became odorless, or the offensive
odor was much mitigated.

In the last stage of tuberculosis Amon saw no beneficial effect from creolin.
In two cases, in which infiltration of the apices, or only slight extension of
the process over an upper lobe existed, a marked and favorable local result
was perceived (diminution of the rales and less dulness). He has used it
successfully in diphtheria. — Schmidt's Jahrbucher, vol. ccxix.

514 PROGRESS OF MEDICAL SCIENCE.

Large Doses of Digitalis in Pneumonia.

Pkof. Petresco gives a most astonishing account of the results of this
remedy in pneumonia. He used an infusion made from one to two drachms
of digitalis leaves, in some cases even three drachms in the twenty-four hours,
with, he claims, complete success.

Since 1883 he has employed in pneumonia nothing except an infusion of
one drachm of digitalis leaves in eight ounces of fluid, a tablespoonful evtrv
half hour. As a rule, the malady was strangled in three days. "The fever
and all the physical signs, local as well as general, disappeared as if by
enchantment."

The temperature fell, after about three doses of a drachm of the leaves, from
104°-105° to about 96°; the pulse from 120-130 down to 30-36, a minute.

The general condition of the patients improves in a most surprising man-
ner; they wake up as if from a sound sleep, express themselves as feeling
very well, and ask for something to eat.

The mortality in these cases was only 1.22 per 100. He even goes so far as
to say that he is convinced that the mortality in this disease may be reduced
to zero if these doses are given early.

As illustrating the tolerance and harmlessness of these doses of digitalis
he refers to 577 observations published in his treatise on Tlierapeutics, in
1884, and to the theses of his students. — Gazette Hebdomadaire, Aug. 24, 1888.

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLER, M.D., F.R.C.P. Lond.,

pbopessob or clinical medicine in the university or Pennsylvania.
Assisted by

J. P. Crozer Griffith, M.D., Walter Mendelson, M.D.,

ASSISTANT PHYSICIAN TO THE HOSPITAL Or THE PHY81CIAN TO THE BOOSEVELT HOSPITAL, OUT-

t MVEB8ITY OP PENNSYLVANIA. DOOB DEPABTMENT, NEW TOBB.

On Veratrum Viride in Diphtheria.

In 1881, J. M. Boyd {Medical Record, 1888, 88, 627) was induced to give a
child of four months, suffering from malignant diphtheria, full doses of
Norwood's tincture : viz., a drop every two hours. After four or five doses
the pulse fell from 180 to 80, and coincideutly with this the abundant de-
posit melted away with great rapidity, and in twenty-four hours the ooctaafao
Of the nose and larynx had so far disappeared that the child was again able
to nurse. Since this time the author has seen upward of seventy cases of tin-
disease, and in no instance has the timely use of vrratrum disappointed him.
The medicine should be given early and in full doses, and made the essential
ire of the treatment; the slowing of the pulse being the nm qua Mm.

MEDICINE. 515

The pulse of diphtheria is characteristic; being tense, wiry, and rapid. The
vfeoownen <>i' tin- attack may be better measured by the tension and s[
of the pulse than by any other feature. If the heart is slowed by the verat-
ruin, the rapidity of the circulation is lessened and the inflammatory pro-
. s about the seat of lesion are mitigated. Under the positive influence
of the drug, the system appears to have a tolerance for the diphtheritic
poison, and there is shown a resistance to the further progress of sepsis and
to the spread of the membrane. The author does not fear asthenia from the
use of veratrum, but dreads rather exhaustion from persistently rapid heart-
action. Rest the tired heart, and the economy will take on recuperation and
resistance to the poison, and the best protection against asthenia will be
found. The dose for an adult is three drops every two hours, adding one
drop each dose until the pulse is reduced to 60 or 70 per minute. If vomit-
ing is a troublesome symptom, the dose must be increased cautiously or
omitted occasionally.

Antipyrine as a Specific against Whooping-cough.

Soxnenberger (Therap. Monatsheft., August, 1888), writing again on this
subject, considers antipyrine a specific in this disease. He gives it in some-
what smaller doses than those used for fever, administering about as many
centigrammes as the child is months, and as many decigrammes as it is
years old. With older children a proportionately smaller dose will prove
efficient.

The drug is best given three times daily with, perhaps, an additional dose at
night. In these small doses it can be given continuously for weeks without in-
jurious results, a very important matter, since it is on this continuous adminis-
tration of antipyrine that rapid recovery depends. In general, the earlier in the
disease the drug is employed the better is the result. If the opportunity pre-
sents itself to use the drug before the characteristic attacks have been fully
developed, we may often cut the disease short, or at least change it into the
appearance of a mild bronchial catarrh. If the treatment be commenced in
■ mnewhai later stage, the symptoms may be very greatly reduced in severity,
and but six or seven mild paroxysms will occur in the twenty-four hours. In
still later ■tagee, when the disease is at its height, the action of the drug is by
no means so remarkable, but the good influence is still seen after some days.
The attack- become milder and less frequent, and expectoration more
abundant ; and the disease rapidly goes into the Vadium dteremtnti.

Antefebrin act* far less favorably than antipyrine in controlling whooping-
cough.

Catalytic Action of Electricity in Rheumatic Affections.

G. L. Walton {Boston Medieal and Surgieal Jour mil, 1888, exix. 101)
quotes several writers in evidence of the catalytic action of electricity. It
appears that it is especially useful in rheumatic affections of muscles and
joints of a subacute type, and that by the use of galvanism exudation and
pain may be made to disappear. The author reports two cases treated suc-
cessfully in this way. The first was one of rheumatism of the wrist and hand,
which had lasted two months and had rendered flexion of the fingers impos-

516 PROGRESS OF MEDICAL SCIENCE.

sible. Motion and massage were painful, and there was some atrophy of the
muscles of the hand and forearm. Electricity was employed for twenty
minutes daily; the galvanic current being passed through the wrist and
fingers, and galvanism and faradism being applied to the muscles. Improve-
ment began at once, and by the end of a week pain had nearly disappeared and
motion was returning ; and at the end of five weeks treatment was discon-
tinued as recovery was nearly perfect. The second case was one of rheu-
matic swelling of the ankles which had lasted some months and gave consid-
erable annoyance, though unaccompanied by pain or redness. In this instance
faradism was used every other day. The swelling could be seen to lessen
during the application, the return of it between the applications became less
marked, and in two and a half months the ankles were virtually normal.
Walton has treated several cases of muscular rheumatism with excellent re-
sults, particularly when the muscles of the neck and back were affected.
Several instances of swelling of the ankles, not of a rheumatic nature, and
cases of pain in the heels and soles caused by overuse were surprisingly
benefited by electricity. In this class of cases the faradic current seems to
answer as well as the galvanic.

Acute Febrile Icterus (Weil's Disease).

Since the publication of Weil on this subject, there have appeared articles
by Goldschmidt, Wagner, Roth, Haas, Fiedler, and Hueber. Aufrecht has
also reported two cases, but it is questionable whether they are correctly in-
cluded under this heading. Nauwerk {Miinchen. med. Wochensehr., 1888,
579) now publishes two new cases of the affection. In the first, an insane
woman of thirty-five years/the disease began suddenly with fever, and on the
second day intense icterus appeared over the whole body, and enlargement of
the spleen was evident. There rapidly developed salivation, fall of tempera-
ture, profuse sweating, coma, and death on the third day of the disease.
There was no vomiting or diarrhoea. At the autopsy there was found a
necrosing inflammation of the small intestine, producing small scattered
ulcers reaching to the muscular layer. The liver and kidneys exhibited ex-
treme albuminoid, fatty, and necrotic degeneration of the parenchyma, with
scattered foci of inflammatory cellular infiltration. The absence of bacilli
and the extent of the degeneration indicated the presence of some toxic cause
(ptomaine).

The second case occurred in the person of a butcher, who was suddenly
taken sick with a chill, followed at once by the evidences of being extremely
ill. There were profuse sweats, increased frequency of the pulse, and high
temperature. By the third day icterus developed, and there was frequent
vomiting with meteorism, mental oppression, and delirium. By the sixtli
day diarrhma appeared ; by the seventh, there was transitory diminution of
tin- fever and rapidity of the pulse, and the liver became enlarged. Later
the spleen was enlarged ; on the sixteenth day a roseolous eruption was
risible; and on the eighteenth day death occurred from cardiac weakness and
oedema of the lungs. The autopsy revealed almost the same changes in the
liver and kidneys as were seen in the first case. There was, however, an
entire absence of any lesion of the gastro-intestinal tract.

MEDICINE. 517

Emxnfio Cerebro-spinal Meningitis.

Cerebrospinal meningitis, says Townsend {Boston Mid. arndBury. Journ.,
1888, cxix. 52), first appeared in this country in 1806. Since then there have
been numerous epidemics in different parts of the country, and, besides this,
it is rapidly becoming endemic in many of the cities, especially in New York,
Philadelphia, Chicago, and Jersey City. Since the great epidemic of 1872
the disease has not been absent from New York. It is evidently an infectious
disease, and is as clearly not contagious, in the ordinary sense of the word.
Numerous investigators admit the presence of a micrococcus in the purulent
fluid of the meninges ; and some have claimed that this is identical with
that found in pneumonia. There seems, indeed, to be some relation between
pneumonia and cerebro-spinal meningitis, when viewed from a clinical stand-
point alone, since they not uncommonly occur together in the same patient.
If one and the same microorganism were always the cause of both affections,
there should exist a tolerably constant relation between the number of cases
of the two diseases. The author shows by tables and graphic charts that no
such relation exists, as applies to Boston at least ; and he concludes that either
the ordinary croupous pneumonia has a different origin from the pneumonia
which is produced by the same organism as is cerebro-spinal meningitis, or
certain uncomplicated cases of the latter affection are caused by a different
organism from the one which is thought to produce both diseases. Clinical
a- well as bacteriological studies show that cerebro-spinal meningitis is related
in some way to acute rheumatism on the one hand, and to ulcerative endocar-
ditis on the other.

We may have, first, the fulminant form of the affection, in which death
takes place in twenty-four hours or less; second, the abortive form, charac-
terized by headache, stiffness of the neck, and, perhaps, a few herpes vesicles,
with recovery in a few days ; third, the intermittent form, in which there are
intermissions at irregular intervals, when the temperature is normal, and almost
all the other symptoms may nearly entirely disappear; and, fourth, the typhoid
form. As regards differential diagnosis, the fulminant form is usually readily
recognized, but where very rapidly fatal, may be confounded with cerebral
hemorrhage. The absence of much elevation of temperature aids in dis-
tinguishing the latter affection. Tubercular meningitis is indicated by a
family history, a gradual onset, the evidence of tubercles deposited elsewhere,
and the absence of herpes. Retraction of the head may occur in basilar
tubercular meningitis, but is rarely marked. If tubercles invade the spine, the
symptoms of cerebro-spinal meningitis are exactly reproduced. In simple
meningitis there is a history of traumatism or of middle-ear disease. Trau-
matism is said, however, to have produced the other affection.

The onset of scarlet fever may be marked by severe cerebral symptoms, but
the diagnosis will not long remain in doubt. When it terminates fatally
within twenty-four hours without the appearance of a rash, the diagnosis
from cerebro-spinal meningitis may be impossible. The frequent absence in
children of the cardinal symptoms of pneumonia may render the diagnosis
obscure. Holt says that a slow, irregular, intermittent pulse may be found in
meningitis, but not in pneumonia. A persistent high temperature, with but
little variation, is characteristic of pneumonia, but not of meningitis. If

YOl 96, SO. 5.— NOVEMBER. 1888. 34

518 PROGRESS OF MEDICAL SCIENCE.

in pneumonia there develop persistent retraction of the head, arching of the
fontanelle, severe headache, retardation of the respiration, and frequent con-
vulsions and coma, the contemporaneous existence of cerebro-spinal menin-
gitis is probable. Typhus fever develops more slowly, and u copious macular
eruption appears on the fourth to fifth day. A temporary pain and stiffness
of the neck muscles may be caused by rheumatism ; but there is no headache,
and recovery takes place in a few days. The prognosis of cerebro-spinal
meningitis varies extremely. Twenty to seventy-five per cent, die, but very
severe cases may recover. The treatment consists in opium in large doses to
relieve the extreme pain, bromides, cold applications to the head and spine,
a sustaining diet, and stimulants as indicated. The author closes his paper
with the reports of two cases coming under his observation.

On an Affection Characterized by Astasia and Abasia.

Under this title Blocq (Arch. f. Neurolog., 1888, xv. 24) describes a condi-
tion which has been spoken of by other writers under various names, indi-
cating the inability, on the part of the patient, to stand or walk, although the
sensibility, motor power, and the coordination of other movements of the
lower extremities remain intact. From his own observations and those of
others, he concludes that the disease usually begins rather suddenly with or
without painful sensations, and generally after slight trauma or violent
psychical disturbance. The characteristic symptoms vary in intensity, and
in the lightest cases consist simply of an uncertainty in standing and walking.
The effect of closing the eyes is inconstant ; the tendon reflexes are normal.
Locomotor movements of other sorts, as jumping, walking on one leg or on
all fours, climbing, etc., are unaffected, and all movements are possible when
the patient is in the recumbent position. There are often other nervous
affections chiefly of an hysterical nature. The course of the disease is capri-
cious, though recovery, often sudden, is the rule. The diagnosis is not m
since the disease is to be distinguished from tabes, Friedreich's ataxia, hys-
terical ataxia and paraplegia, chorea, etc. As regards etiology, difficult
parturition and typhoid fever have been noted as causes, in addition to those
mentioned. Often no cause can be found. The same therapeutic means must
be employed as in hysteria.

Rapidly Fatal Chorea.

Cook and Beale (Brit. Med. Journ., 1888, i. 795) report a fatal case occur-
ring in a girl of nine years, in whom the choreic movements constantly
became worse; delirium developed with slight fever, rapid and feeble pulse
and rapid and interrupted respiration ; and death suddenly occurred one
hundred and thirty hours after the onset of the disease. The autopsy re-
vealed extreme anaemia of the pons and medulla, but no other changes of
note in other parts of the body.

A Clinical Consideration of Sixty Cases of Cerebral Parai^

in Children.

In the hist four years at the Out-patient Department of the Children's
Hospital, Boston, Robert W. Lovett (Boston Medical and Surgical Journal,

MEDIC INK. 519

1888, 118, (341) has observed some sixty cases of motor disturbance in which
there Beemed reason to believe that the disability was of cerebral origin.
They could be divided naturally into three groups: 1. Hemiplegia, 2. Spastic
paralysis of both legs. 3. A class of nondescript cases, perhaps best called
incoordination or idiocy. Of the first group there were twenty-six cases,
ranging from one and a half to fourteen years of age. Two-thirds of these
were cases of the adult type, while in the others there was more or less spastic
paralysis of both legs as well. There was, in every case, at the time of ob-
servation a certain amount of impairment of motion of the diseased side.
Muscular atrophy was, as a rule, slight compared with that seen in infantile
spinal paralysis of the same duration. A considerable degree of bone short-
ening was seen in cases which had lasted some time. Facial paralysis had
been present in at least half the cases, and strabismus was still observed in
more than half. Mental impairment was common ; only six of the twenty-
six cases being of average intelligence. Seven cases were aphasic. Though
abnormal parturition is so often the cause of cerebral injury in the child, yet
in the cases of hemiplegia and spastic paralysis there existed no such uni-
versal factor, over half of them being born by normal labor which the
mothers described as easy. All but two of the cases of hemiplegia were
noted within the first two years of life. An illness of some sort, as severe
trying, bowel irritation, indigestion, or convulsions, marked the onset of the
disease in nearly all the patients. Spastic paralysis, in which the legs, and
sometimes the arms, are straight and rigid, the gait is on the toes, the legs are
often crossed, the reflexes are increased, and there is not much wasting of the
muscles — occurred in sixteen cases, not including those in which it compli-
cated hemiplegia. In most of them the disease was noticed immediately
after birth. The mental impairment was even more general than in hemi-
plegia. In more than half there was strabismus ; seven were completely
aphasie ; and twelve were unable to walk at all. In seven cases the hands
were also affected.

The question whether spastic paralysis in children is spinal or cerebral in
origin has been much discussed. The author lays stress on the fact that in
all his cases there was not one which was free from cerebral symptoms. He
quotes several writers to show that the cerebral origin is now the generally
accepted cause. He has examined the records of seventy-seven autopsies of
cases of hemiplegia and of spastic paralysis, and found uniformly a lesion of
the motor tract, atrophy and retarded development of the brain, and de-
scending degeneration of the pyramidal tracts and lateral columns of the
cord. It seems unquestionable that the disease sometimes originates in de-
fective development of the nervous centres, especially the pyramidal tracts.
Since hemiplegia and spastic paralysis differ but little in the original lesion,
it is not strange that they should be sometimes associated. It would seem
that the first affection may gradually pass into the second.

The diagnosis of cerebral from infantile spinal paralysis can usually be
made without difficulty, except at the beginning, when it is practically impos-
sible. Cerebral paralysis is chiefly distinguished by being oftenest hemi-
plegia, while the tendon reflexes are increased, wasting comes on but slowly,
and the reaction of degeneration does not exist. The prognosis of hemi-
plegia is grave; the chances being that mental enfeeblement will develop

520 PROGRESS OF MEDICAL SCIENCE.

and possibly spastic paralysis. In pure spastic paralysis it is probable that
the child will be able to walk somewhat, if the case is not severe, and eventu-
ally to talk more or less badly. The treatment of these affections consists in
mental training, and in keeping the muscles in as good a condition as possible
by the use of the faradic current and massage.

The third group of cases resembles superficially those which have been
already described, but both definite paralysis and spastic rigidity of the
muscles are absent, and idiocy obscures everything. Either the children were
too limp to stand at all, or they stood with the feet far apart, and walked with
a staggering gait and with frequent falls. The reflexes were sometimes
normal, sometimes increased. Disturbances of sensation were common.
Nine out of thirteen cases, which the author saw, were congenital, but it was
hard to find any assignable cause for them. None of the cases showed any
tendency to improvement during the time they were under observation. In
none of the cases was the birth abnormal or difficult, and the author empha-
sizes the fact that in no class of cases of infantile cerebral paralysis does
difficult labor have the influence which has been attributed to it.

The Cerebral Palsies of Children.

Osler {Medical News, July 14, 21, and 28, August 4 and 11, 1888) has
reviewed the clinical material at the Philadelphia Infirmary for Nervous Dis-
eases and at the Pennsylvania Institution for Feeble-minded Children at
Elwyn. Three divisions are made: hemiplegia, 120 cases; bilateral hemi-
plegia, 19 cases; and paraplegia, 11 cases.

Hemiplegia is a common affection in children, according to some writers
occurring as frequently as spinal paralysis, but at the Philadelphia Infirmary
for Nervous Diseases the proportion is not quite 1 in 4. Of the 120 cases, 5
were boys and 63 girls. There was right hemiplegia in 68 and left in 52
cases. Of 110 cases at which the age at onset was noted, 15 were congenital, and
in 81 the disease came on within the first three years of life. In 9 cases the
children were delivered with forceps; 3 were due to trauma; 16 followed tin-
infectious diseases. In the majority of cases the disease begins with convul-
sions and the hemiplegia is noticed when the child recovers consciousness.
Incomplete recovery is the rule, but the patients are liable to the serious
sequences of epilepsy and mental disorders. 31 cases presented post-hemi-
plegic movements. The result of an analysis of 90 autopsies is given. In 16
instances there were vascular lesions, as plugging of a Sylvian artery in 7, and
hemorrhage in 9. The age at the outset in this group was high ; as, exclud-
ing 3 congenital cases, there was only 1 under three years. Atrophy and
sclerosis were met with in 50 cases. 2 instances are recorded of sclerosis from
the Elwvn Institution. Porencephaly was present in 24 cases.

Minimi! tpcutk hemiplegia is characterized by a spastic condition dating
from or shortly succeeding birth. There is no wasting; the reflexes are in-
creased, the mental condition profoundly disturbed and ataxic, and athetoid
movements of the most exaggerated kind may occur. 19 cases are described :
2 of bilateral athetosis. In 16 reported autopsies the condition has been either
OOrtiol sclerosis or porencephalus.

Spattic paraplegia in children is closely related to bilateral hemiplegia, but

MEDICI XF. 521

th.' arms are not affected. It dates from birth or comes on within the first years
of life. The legs are stiff, the heels raised, and there is strong adductor spasm.
Thf patient walks on the toes or there is cross-legged progression. The intel-
lect is not so profoundly impaired as in bilateral hemiplegia. 11 cases are
ribed. The morbid anatomy of this affection is not yet clear. Only one
autopsy by Fo'reter i> reported (from the Dresden Children's Hospital). Cere-
bral lesion with descending degeneration was present. The reasons are given
for believing it to be of cerebral origin, as Heine suggested many years ago,
when he named the disease paraplegia cerebralis spastica.

In the discussion on the pathology of the cerebral palsies, apoplexia neona-
torum is held to play an important part in the production of the bilateral
hemiplegia and paraplegia. In hemiplegia there is still much doubt as to the
nature of the initial lesion. Strumpell's poliencephalitis has not yet been
demonstrated anatomically, though the view is very plausible, and subsequent
autopsies may show the truth of it. The relation of the cases to the infectious
diseases may be due to embolic processes associated with endocarditis, to
arteritis or periarteritis such as has been described in the heart in typhoid
fever, or to changes in the cerebral gray matter similar to those which have
been described in the cord in measles by Barlow. The conclusion is reached
that infantile hemiplegia is the result of a variety of different processes, of
which the most important are: (1) Hemorrhage, occurring during violent
convulsions or during paroxysms of whooping-cough. (2) Post-febrile pro-
cesses: (a) embolic, (b) endo- and periarterial changes, (e) encephalitis. (3)
Thrombosis of the cerebral veins. Under the section on treatment the ques-
tion of operative interference is discussed and two cases are noted in which
trephining was performed for Jacksonian epilepsy following infantile hemi-
plegia. These are held not to be suitable cases for operation.

Tetany.

J. Hoffmann {Dmhch. Arrh., 1888, xliii. 53) publishes a valuable paper,
based on eleven cases of tetany, reported in full, and accompanied by
numerous references to cases of other observers and their opinions concerning
the disease. In all but one of the author's patients the affection began be-
tween the ages of sixteen and twenty-five years. He is disposed to believe
that the nature of the occupation is not without influence on its etiology, and
that shoemakers, seamstresses, clerks, etc., are, perhaps, especially liable to it.
After reviewing at some length the literature relating to the bearing of the
thyroid gland on tetany, he concludes that, in all probability, the removal of
this organ is one of the etiological factors. He does not agree with Strumpell
that there are endemic influences in its production. The spasm was rather
widely spread in the cases which he reports, and was always bilateral. The
attacks lasted from several minutes to some hours, and in one instance ten
days. The premonitory fibrillar muscular trembling was absent in most cases;
the tendon reflexes were usually normal, but in one case diminished, and in
another nearly absent. The attacks of spasm were always preceded or accom-
panied by paraesthesias. Trousseau's symptom (the production of an attack by
compression of the main artery of a limb) was always present during the
height of the disease, while the compression of a nerve had this effect in but

522 PROGRESS OF MEDICAL SCIENCE.

one case. The disappearance of this symptom is in no sense a sign that the dis-
ease has terminated, but only that it is in abeyance. The galvanic and faradic
electrical excitability of the nerves was much increased in all cases in which
it was carefully examined; and even the facial and the hypoglossal nerves
may share this excitability. An increase of the mechanical excitability of
the motor nerves was absent in but one instance. A series of experiments
convinced the author that the mechanical and electrical excitability of the
sensory nerves is increased. The disease lasted in the author's cases from
half a year to twenty-one years. Most commonly the attacks occur in groups,
lasting some weeks, and with variable periods between them, in which there
exist only certain symptoms of latency ; or the intervals may continue for
years, with absolutely no sign of the affection.

According to most authorities, the prognosis is favorable, though the dis-
ease may last for years. Death occurs only exceptionally, from exhaustion or
spasm of the diaphragm. Certain of the author's cases exhibited evidences
of paralysis, for which the tetany was apparently responsible. Frequent
shedding of the finger-nails and a brown pigmentation of the skin of the
hands and face was observed in one instance, and the author considers the
probable cause of the latter to be nervous influence combined with repeated
small extravasations of blood into the skin, induced by the muscular spasm.
Hoffmann reports the results of autopsies which have been made, and quotes
extensively the opinions of various writers concerning the pathological
anatomy of tetany; all of which indicates that, though fine molecular nutri-
tive changes of the nervous system are almost universally considered to be
the cause of the disease, making it, therefore, a neurosis, the seat of the
changes is still a much disputed point. He obtained the best therapeutical
results from bromide of potash, morphia, and the galvanic current. In an
appendix the author reports four additional cases of the affection, in two of
which shedding of the nails took place, accompanied, in one instance, by
falling out of the hair. He shows still further the positive influence of ex-
tirpation of the thyroid gland on the production of tetany, and calls attention
to the fact that attacks seldom occur in summer, cold seeming to be a strongly
exciting factor.

Revival of Tartar Emetic in Treatment of Pneumonia.

The amount of attention that has been given this ancient use of an old drug
shows that it has not been so quite forgotten everywhere as it seems to have
been here in America. Cf. Mosler, Deut. med Woch., 1887, p. 1031 ; Bruck-
ner, ibid., 1888, 1, No. 22, p. 447 ; ibid., August 16, 1888, p. 686.

In Germany the drug has been given after the method of Lebert. Of tartar
emetic gr. jss-gr. v are ordered in ^vj of water, of which solution ^ss (= gr.
\ 4- ) is given every hour till vomiting or diarrhoea occurs, and then every
two hours. In most cases these symptoms from the side of the gastro-intes-
tinul tract will cease even under the continued use (Lebert, Bruckner) ; if not,
or if opium does not control them, the remedy is to be given up. The toler-
ance is very variable. Usually, after one or two doses, there is vomiting, which
brings great relief, then four to eight watery stools, then sweating and an
increased expectoration. The pain and dyspnoea are much relieved. The

MEDICINE. 523

well-ascertained physiological action of tartar emetic is in diminishing the
blood-pressure, and its therapeutical action in pneumonia is probably to be
found in this effect on the pulmonary circulation (Lebert). The clinical
results from its use in the hands of these observers have been encouraging.
Certainly most physicians would rejoice to have forty successive cases in
hospital practice without a death! (Mosler).

Dr. Arthur Jamison, basing his conclusions on the careful study of 213
personally observed cases, in 155 of them has acquainted himself with the
later history of the case and secured the opportunity of a physical examina-
tion at a period not less than two years after the attack. This after-history,
he considers, should be the guide to treatment, for in 74 of the 155 examined
he found traces of an unresolved pneumonia, viz., dulness of affected side,
. etc., and 12 of the cases died of phthisis. Of the 81 found free from
signs 65 had been treated by tartar emetic Not only did physical signs per-
sist in many cases, but he ascertained that many patients, though discharged
as well after treatment by the usual methods, had for months some cough and
expectoration, constant feeling of uneasiness, flatulent distention after meals,
and in general were not up to par. On the basis, therefore, of much compara-
tive trial of all methods of treatment, coupled with this after-investigation,
Jamison recommends tartar emetic as a continued remedy, ascribing to it the
merits of relieving the distress of the first stage and of easing the strain of
breathing, while it is superior to everything else in inducing the greatest
degree and rapidity of resolution, as tested by the after-condition of the lung.
He gives it in doses of one-twentieth of a grain for young adults every hour,
but less frequently to older persons. When the symptoms are relieved it is
given less often, but still continued several days or even a week after defer-
vescence. In no case of the large number treated has it caused either vomit-
ing or diarrhoea. It is combined with a little paregoric. Dilute nitric acid
is preferred in the after-treatment. — Brit. Med. Journ., June 30, 1888.

Paczkowski also reports a very large series of 532 pneumonias treated by
Kermes mineral (antimon. sulphurat.). The mortality in this great series
WM only 1.69 per cent ! The drug should be freshly prepared, and the earlier
given the better. He makes the astonishing statement that if given on the
second or third day the crisis occurs within twenty-four hours, sometimes in
eight. It is given in the following formula :

Kermes mineral gr. xxx.

Ext. digitalis gr. ijss.

Opii . . . gr.j.

Divide in pil. no. xxxij. Two pills every two hours, and after the crisis
two every three hours till convalescence is established. — Deut. med. Woch.,
1888, No. 29, p. 607.

Creasote and Iodide of Potash in Phthisis.

G. Stdecker (Therap. MonaUhef., 1888,385) has studied the conditions for
the employment of these two drugs, and concludes from his experience that
each has its limited sphere of action. Creasote is useful in those cases of
phthisis of the nature of caseous pneumonia ; while iodide of potash is to be
preferred in fibroid contraction of the lung with adhesive pleuritis. In

524 PROGRESS OF MEDICAL SCIENCE.

mixed forms of cheesy and fibrous tuberculosis the one or the other of the
two drugs is to be employed, depending on whether the cheesy or the fibrous
element predominates. In a third group of cases, in which the involvement
of the bronchial mucous membrane produces a purulent or mucous bronchitis,
the employment of the iodide is entirely excluded, and the balsams are to be
given with or without creasote. A fourth group, in which the symptoms of
emphysema are predominant, is to be treated with iodide of potash. Contra-
indications for the use of creasote are tuberculosis of the intestine, amyloid
degeneration, and the late stages of phthisis. Contraindications for the use
of iodide of potash are tendency to haemoptysis, even slight lesions of the
larynx (on account of danger of oedema of the glottis), ulcerative processes
in the trachea, insufficiency of the kidney of whatever nature, and severe
iodism.

Movable Heart.

Rumpf ( Therop. Monatsfie/., 1888, 382) reports five cases of extreme mova-
bility of the heart, arising after the treatment of obesity or from emaciation.
In one case, in which the treatment had caused a loss of fifty pounds, all the
organs were normal, and when the patient was erect or lying on the back, the
cardiac dulness was in the usual position and of the usual shape. When,
however, he lay on the left side, the apex beat was removed to the middle
axillary line, and the cardiac dulness left the sternum, only touching it at
the insertion of the third rib. If now a position on the right side was
assumed, the absolute heart dulness disappeared entirely, and a relative
dulness of only two centimetres on each side of the sternum was found, ex-
tending from the fifth rib to the sixth intercostal space, while the impulse
was felt close to the sternum in this space. The total range of movement of the
apex beat equalled thirteen to fourteen centimetres. The physical examina-
tion of the other four cases gave very similar results. The symptoms of all
were weakness, dizziness, and inability to lie on the side. When the attempt
to assume this position was made, there developed pain, oppression, a sense
of anxiety, and an increase of fifty to sixty beats in the pulse rate.

An interesting question is, whether the loss of fat resulting from the treat-
ment was the cause of the abnormal movability. The examination of a
large number of healthy men showed that only a slight displacement of the
apex beat or of the cardiac dulness occurred on change of position. On the
other hand, in a number of advanced cases of pulmonary tuberculosis with
great loss of bodily weight there was a very considerable displacement of the
apex beat when the patient was lying on cither side. The same condition
was observed in a patient with progressive muscular atrophy, who had lost
forty pounds weight. The author does not hesitate, therefore, to consider the
treatment for obesity the essential cause of the abnormal movability of the
.11 the cases which he reports,

Cov.r . ii u. Narrowness of the Aortic System.

0. 1 i. (Deutsch. medicin. Wochenschr., 1888, 589) reports several

cases of disease of the circulatory apparatus apparently due to a congenital

MEDICI NK. 525

narrowness in the aortic system. Two of the cases were confirmed by autopsy.
The subjective symptoms are those of heart disease, but the heart sound-
clear, the second sound often accentuated, and the heart exhibits some dila-
tation. The symptoms are especially like those of cardiac overstrain, but
develop in persons who have undergone no, or but slight, exercise. The
hypertrophy of the heart begins in youth, is followed by dilatation, and finally
by the signs of insufficient compensation. The arteries of the body are small,
their tension high, and the face often strikingly pale. It is probable that the
cases of congenital narrowness of the aortic system are much commoner than
has hitherto appeared.

A Study of the Arteries and Veixs in Bright's Disea-k.

Arthur V. Meigs {Medical Record, 1888, 34, 1) reviews somewhat the state
of the question regarding the origin, nature, and relations of Bright's disease
and of heart disease, and illustrates his remarks by microscopic drawings of
sections of the bloodvessels. He concludes that in the so-called chronic
Bright's disease we have to do with an affection widespread in its effects, and
that the most characteristic and probably most important changes are those
of the intima of the arteries; in which changes it is likely that the veins
always participate. Alterations in the muscular coat and the adventitia, though
often present, are probably secondary to those of the intima, and are by no
means so important in their effects. The process seems to be coextensive
with, and, it is likely, is a part of the change in the large arteries which is so
common and so well known as atheroma. Finally, in the absence of knowl-
edge concerning the participation of the nerve substance, it seems most
probable that the earliest of the now known pathological steps to make its
appearance is the alteration of the intima of the bloodvessels.

The Etiology of Acute Bright's Disease.

Juli aberg ( Centralbl.f. klin. Med., 1888, 537) reports eleven cases

of acute Bright's disease, in eight of which he found the streptococcus discov-
ered and described by Lustgarten and himself some time ago. The quantity
of the cocci always stood in direct proportion to the severity of the disease
in general, and to the variations in the phases of the individual cases. In
fatal cases the urine often contained enormous numbers of the microorganisms.
In other cases the numbers diminished as the secretion of urine increased,
and completely disappeared when the other symptoms began to abate. They
could not be distinguished morphologically from the streptococci of erysipelas
and of pus, but through cultures, which the author describes, were found to
be entirely different from species previously known. They may be stained
by various aniline colors, but it is necessary to avoid heating the cover-glaas
in drying the specimen. Control experiments made on the urine of various
patients with pathological conditions, including contracted kidney and
passive congestion, amyloid degeneration, and tuberculosis of this organ, in-
variably failed to reveal any of the cocci. Experiments with animals showed
that the cocci were decidedly pathogenic, at least for dogs and rabbits. There
were produced, namely, more or less intense evidences of disturbance of the kid-
neys three or four days after inoculation. Renal epithelium, blood, casts, haema-

526 PROGRESS OF MEDICAL SCIENCE.

toidin crystals, albumen, and streptococci were found in the urine, and the
last mentioned proved themselves identical with those used for inoculation.
The author believes, therefore, that certain forms of idiopathic acute Bright's
disease are the result of the action of bacteria; it being already admitted that
nephritis occurring in the course of the general infectious diseases is of this
nature.

Hydrops Intermittens Articulorum.

Fridenbero (Medical Record, 1888, 33, 657) reports, from his own practice,
two cases of a peculiar vasomotor affection of the joints, and collects twenty-
four others from the literature of the past twenty years. This consists of a
serous exudation into one or more joints, arising without appreciable cause,
and recurring and subsiding spontaneously at certain definite periods. It
would certainly appear to be a vasomotor neurosis, since in five cases palpi-
tation, syncope, exophthalmos, rigors, and transpiration were also noted ; and
in two instances there were fully developed symptoms of Basedow's disease.
Various marked emotional disturbances were present in others. Pregnancy
exerted a remarkable influence in eight out of nine cases in which it occurred,
in that there was meanwhile a complete cessation of the attacks. The exact
pathology of the affection is uncertain, as no case has come to autopsy yet.
The rapidity with which the effusion appears and is again absorbed, shows
that it is a passive non-inflammatory dropsy due to some temporary interfer-
ence with the vasomotor control. Periodicity is a very marked characteristic,
as it often is of other vasomotor diseases. It has not in these cases anything
to do with malaria. In the only one of the author's cases to whom treatment
could be regularly given, great permanent improvement, and even temporary
cure followed the application of galvanism to the medulla, combined with
tonic and alterative medication.

Calcium Chloride in Glandular Affections of the Neck.

Thomas J. Mays (Archives of Pediatrics, 1888, 471) reviews the employ-
ment of calcium chloride, formerly used in scrofulous affections. He has
used it for several years, especially in scrofulous affections of the neck, and
found it to act admirably in many cases in which cod-liver oil internally and
i'Mline externally had proved futile. It can be given in milk or water in
doses of two to four grains for children, and ten to twenty grains for adults.
The best vehicle, however, is syrup of sarsaparilla. It must not be con-
founded with the chloride of lime used for disinfecting; and to avoid this
confusion tlir granular chloride of calcium should be ordered.

Naphthol in Stomatitis.

D- W. Loi Koai Record, 1888, 33, 664) has used naphthol in several

cases of stomatitis with good results. It is indicated wherever a reliable dis-
infectant ami antiseptic is required. In a case of mercurial stomatitis it gave
almost immediate relief to many of the unpleasant symptoms, and in a case
of stomatitis in a woman which had resisted ordinary treatment it was all

SURGERY. 587

that could be desired. It may be used as a mouth wash or gargle, is not un-
pleasant in taste, and is non-poisonous in its effects on the system.

Lactic Acid and Diet in Infantile Diarrhoea.

Frank Wiiitefield Shaw {N. Y. Med. Journ., 1888, xlviii. 123), fol-
lowing the rules laid down by Hayem, has been employing lactic acid in the
BO diarrhoea of infants. He has also extended its application to all forms
of infantile diarrhoea, and with excellent results. Since 1887 he has adminis-
tered this treatment to over 100 patients, varying in age from ten weeks to
twenty-four months, and with great variety in the intensity of the disease.
A child under twelve months received one-half a teaspoonful of a two per
cent, solution every hour; or if the discharges are very frequent, a teaspoonful
every hour for six doses, and then a half a teaspoonful every hour. Over
twelve months, a teaspoonful is the ordinary dose. Within a period of twelve
to seventy-two hours the character of the alvine discharges begins to change;
the greenish becoming less watery and assuming a yellow tint, and the
yellowish watery, or the bloody passages assuming a greater consistence
without the offensive odor. The general results were so satisfactory that the
author has abandoned all other drugs in this disease. Under its use also
vomiting is controlled, temperature reduced, intestinal pain quieted, and
restlessness and sleeplessness overcome.

As most of the patients treated were of the poorest class, he gave special
attention at the same time to a proper regulation of the diet. An exclusive
diet, either of breast milk or of artificial food, did not seem to give good results.
Food too rich in fat cannot well be tolerated, and as mother's milk is some-
times open to this objection, a small quantity of the prepared food was admin-
istered before nursing. The proportion of caseine, too, was rendered smaller
thereby, and when lactic acid was also employed as the medicine, recovery
sually speedy.

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

•URQEOX TO THE PHILADELPHIA AND GERMAN HOSPITALS; CLINICAL PROrEMOE OF OEM ITO-D RIKA RY
gCRQERT IS THE fXIVEBSITY Of PENNSYLVANIA.

Tk aumatic Aphasia relieved by the Removal of a Blood-clot
from the Cerebrum.

Ball {Dublin Journal of Medical Science, September, 1888) records a case of
peculiar interest successfully operated on by him for the cure of aphasia.
The patient had been struck a blow in the head with a penknife ten days
before admission to the hospital. He had noticed, since the blow, increasing
difficulty in using the right words. On examination a small scab was found

528 PROGRESS OF MEDICAL SCIENCE.

adherent to the scalp, over the squamous portion of the left temporal bone.
This, when detached, showed a cicatrix extending deeply through the tem-
poral muscle. There was well-marked motor aphasia, word-blindness, and
word -deafness. No paralysis could be detected. Five days after admission,
as the symptoms had increased, an operation was determined on. A flap was
turned down including the cicatrix, and a wound of the squamous portion of
the temporal bone, such as could be caused by the small blade of a penknife,
was found. A circle of bone was removed, containing in its centre the wound
In the bone. The knife was found to have penetrated the dura mater and
brain. The dural wound was enlarged and a Sims' forceps was passed into
the brain wound, and was gradually separated. A dark-colored blood appeared
and was extruded by the internal brain pressure ; more clot was removed by
Sims' forceps and weak perchloride irrigation, a drainage tube was introduced,
and the external wound was sutured. On the evening of the same day the
patient carried on a long conversation with very few mistakes in his selection
of words. The following morning aphasia was again increased, but disap-
peared on cleaning the blocked drainage tube. The recovery was, after this,
uninterrupted and complete.

Traumatic Sub-dural Abscess of the Brain.

Stokes (Dublin Journal of Medical Science, September, 1888) alludes to
eleven recorded cases of sub-dural traumatic abscess treated by trephining,
with successful issue in five. He also records two cases operated on by him-
self, in the first of which the abscess was not reached and the patient died.
In the second the abscess was only found by sinking a hypodermatic needle
to its whole depth into the brain substance. An ounce and a half of pus was
removed, and the abscess cavity was washed out with a one per cent, solution
of carbolic acid.

In connection with these cases Stokes makes the following propositions :

1. That after the primary symptoms of cerebral traumatism have subsided,
there is frequently a latent period of varying length during which there are
no distinct brain symptoms connected with abscess formation whatever.

2. That their appearance is, as a rule, sudden, and, if uninterfered with, run
a rapidly fatal course.

3. That the occurrence of pus production resulting from cerebral trauma-
tisms is not incompatible with a perfectly afebrile condition.

4. That this latter fact will probably aid in differentiating traumatic cere-
bral abscess from meningeal or encephalic inflammation.

5. That both as regards color and consistence there is great variety in the
contents of cerebral abscess cavities, and that, as shown in Wilm's case, pub-
lished liy Rose, of Berlin, they may be transparent.

I hat antisepticism has largely diminished the risks of the operation of
trephining.

7. That having regard to the great mortality of eases of cerebral abscess
when nninteriered with — viz., from 90 to 100 percent. — the operation is indi-
cated even when the patient is in ofuMti.

8. That in the ctM in which the trephine opening does not correspond to the
situation of the abscess, exploratory puncture and aspiration may be employed.

SURGERY. 529

9. That by the adoption of this measure the necessity for multiple trephine
openings can be largely obviated.

10. That the employment of a blunt-pointed aspirating needle, as suggested
ntz, is probably the safest mode of exploration and excavation.

11. That drainage is desirable in the after-treatment of such cases.

1l'. That both during and subsequent to operative interference in these
cases a rigid antisepticism is imperatively required.

Splenectomy.

Two cases of splenectomy, performed by Fritsch, are reported by Asch
{Archir J'iir Gynakologie, Bd. 13, Heft 1).

1. .Married woman, set. thirty-one, has menstruated regularly since her
eighteenth year till the middle of May, 1887. Since the second week in
March has suffered slight pain in the region of the spleen, and has felt a
small nodule beneath the lower border of the ribs. For this and loss of
appetite she consulted a physician. Examination showed a moderate en-
largement of the spleen, without noticeable change in other organs. Together
with increasing languor and complete anorexia there was a steady increase in
the size of the tumor.

Admitted to the hospital June 20, 1887. Present condition : small, feeble
woman, of moderately anaemic appearance. Thoracic viscera normal ; abdomen
projected on the left side by a firm movable tumor, extending from the left
nipple line two and two-fifths inches below the border of the ribs, to the linea
alba, midway between the umbilicus and symphysis ; about nine inches in
length, in the form of a bean, convexity outward, notched at its upper third.
Uterus somewhat enlarged, slightly retroverted, movable, with virginal but
patulous os. Blood normal ; no disturbance in the proportion of white to red
corpuscles. From the rapid growth of the tumor and the healthy condition of
the organs, the diagnosis of neoplasm of the spleen (probably sarcoma) was
readily made. The condition of the womb indicated pregnancy in its first
month.

After the customary preparation for laparotomy, the operation was begun
by a four-inch incision in the linea alba, beginning two inches above the um-
bilicus, and sweeping around the latter to the left. The tumor, dark blue-red
in color, had formed no adhesions and was slowly pressed from the abdominal
cavity. The pedicle was formed by the two layers of the gastro-splenic
omentum investing the vessels. The tail of the pancreas was in close relation
to its upper part. The pedicle was transfixed by a needle carrying a double
silk thread, tied in two sections, and cut two-fifths of an inch peripherally
to the ligatures. The two omental leaflets were then united by a continued
suture, and the whole pedicle finally included in a ligature, leaving a small
but well-fortified stump. This was coated with iodoform, returned to the
peritoneal cavity, and the abdominal wound was closed by means of deep silk
sutures and an occlusion bandage. The operation lasted twenty-five minutes.

The case ran an apyretic course; the wound healed by primary intention ;
the patient was discharged cured in less than three weeks from the time of
operation. There was slight swelling of the inguinal and axillary glands, but
no enlargement of the thyroid. The examination of the blood showed it to

530 PROGRESS OV MEDICAL SCIENCE.

be normal. The patient complained of a dry throat and some cough. Her
pregnancy ran a natural course, and terminated in the birth of a dead child,
which one month before had been living. The patient had felt no motion for
eight days previous to delivery. Both foetus and after-birth were extruded
with extraordinary ease, and convalescence was rapid and uninterrupted.
The cough and the pain in the left side, of which the patient had previously
complained, left her; her appetite increased, and she is now in perfect
health. The tumor weighed five and a half pounds, and proved, on micro-
scopical examination, to be a lympho-sarcoma.

2. Woman, set. twenty-six; delivered of a healthy child at full term, Feb-
ruary 4, 1887. On the fifth day the patient left her bed, but felt from that
time increasing languor and weakness. In spite of a good appitite and the
ingestion of an abundance of nourishing food, the patient became rapidly pale
and emaciated. Fourteen days after delivery a painful nodule was observed
in the splenic region, which rapidly increased in size. There was pain,
becoming more acute for a time, but gradually diminishing till in five weeks
it entirely disappeared. The nodule, however, grew with great rapidity.
After a period of fruitless treatment with quinine, iron, and other medicines,
an operation was determined upon. Examination showed an exceedingly large
tumor of the spleen. The whole abdominal region of the left side from the
ribs to the pelvis was taken up by the smooth, hard swelling. Dulness on
percussion began a hand's breadth above the lower border of the ribs, and
extended toward the right as far as the ensiform cartilage, downward to the os
pubis. A deep notch could be felt a finger's breadth above the navel, in
the inner border of the growth. The patient was extremely blanched and
emaciated ; the pulse was rapid ; there was some dyspnoea. No abnormality
of any organ except the spleen ; no glandular enlargements; no tenderness
over the sternum or any other bone ; no hemorrhage ; no disturbance of
vision ; menstrual flow slight but regular. Patient complained of great giddi-
ness, constant pain in the head, shaking and shivering of the bones, and ex-
treme exhaustion on the slightest effort, but suffered principally from short-
ness of breath, and the mechanical burden of her tumor. On examination of
the blood the relation of white to red was as one to eight. The patient in-
sisted upon an operation, although medical treatment had produced a distinct
gain in strength and general condition.

Incision in the middle line six inches long ; no adhesion to the parietal
peritoneum. The tumor was carefully pressed from the abdominal cavity, &
slight intestinal adhesion was ligatured and tied without loss of blood, the
moderately broad pedicle was ligated in several portions, and, four-fifths of
an inch peripherally to the line of ligature, the tumor was cut away. The
stump was carefully examine!, included in a final ligature, and returned to
the abdominal cavity. No bleeding could be observed, either from the stump
or from a small surface lying near it, where the spleen had been adherent.
The haemostatic forceps placed on the bleeding points of the abdominal wound
were removed without a recurrence of hemorrhage, and after a few mini;
observation the incision was closed by deep sutures, placed closer than usual.
and a very tight occlusion dressing. No symptoms of danger for four hours,
when the patient became rather suddenly short of breath ; the pulse was 96
to the minute, and moderately full. No blood was found on the dressings.

SURGERY. 631

The dyspnoea progressively increased till the respirations became gaspinir,
and the patient perished five hours after the completion of the operation.
The pulse was never above 100 to the minute, and was, in relation to the other
signs of anaemia, surprisingly full.

The extirpated spleen weighed sixteen pounds, and presented the typical
picture of leucaemic hypertrophy.

Autopxy. A large coagulum in the subcutaneous connective tissues about
the wound. Peritoneal cavity filled with reddish-brown blood. About the
former position of the spleen numerous scattered sub-peritoneal hemorrhages.
Similar effusions into the great omentum.

Of 90 splenectomies, tabulated by Asch, 51 were successful. The majority
of these successful cases were for prolapse. Fourteen times the operation has
been successfully performed for the cure of wandering spleen, three times for
cystic degeneration, twice for sarcoma, four times for hypertrophy of the
spleen, once for echinococcus cyst, once for leucffimic enlargement.

The thirty-nine unsuccessful cases were all subjected to operation for the
removal of large splenic tumors. Twenty-one cases were leuca?mic. There
is more or less probability that the other unsuccessful cases were not leucamie.
Death occurred in most of these cases within a few hours of the operation.
The cause of death was, with one exception, extensive bleeding.

From this table it would appear that for various diseased conditions of the
spleen extirpation is safe, easy, and justifiable, but that leue«mic enlarge-
ment should constitute a distinct contra-indication to the operation. To this
opinion Asch does not conform. The danger of leuca;inic hypertrophy rests
on its bulk, and operations should be undertaken early in these cases.
The rule should be, " if it is decided to remove a spleen, whether it be leu-
ca?mic or diseased in other ways, an early operation must be advised."

lii moval of Carcinomatous Tonsil by External Incision.

Fowler {Brooklyn Medical Jour/ml, vii. No. 9) reports a case of primary
carcinoma of the tonsil removed by external incision.

Mrs. L., aged sixty -seven, suffered for nine months from an enlargement of
the left tonsil, which interfered with deglutition. Two cousins had died of
breast cancer. On examination a lobulated slightly movable growth the size
of an English walnut was found, occupying the site of the left tonsil. Lymph-
atic enlargement beneath the posterior border of the sterno-mastoid. Pain,
aggravated by swallowing.

Etherized. Head extended and turned to the right. Incision from just
below the lobe of the left ear down along the anterior border of the sterno-
mastoid to a point slightly below the level of the hyoid bone. To the lower
extremity of this incision was carried another, beginning midway between
the angle of the jaw and the symphysis menti. The flap was drawn up.
External jugular tied and divided ; the facial and lingual arteries treated in
the same way. The hyoid attachment of the stylu-hyoid was divided, the
muscles and other structures retracted, the tumor pressed outward by the
fingers passed into the mouth, and all diseased tissues removed by means of
the galvano-cautery. The incision was now prolonged backward, the enlarged
lymphatics, some of them adherent to the sheath of the common carotid,

532 PROGRESS OF MEDICAL SCIENCE.

were shaved away, and the wound was drained, sutured, and dressed.
Healing was, in the main, by first intention. The patient was entirely
relieved of her dysphagia, and she suffered from no recurrence of the disease
in situ, though she finally perished from gastric cancer.

For the performance of external pharyngectomy Wheeler makes an incision
from the greater coruu of the hyoid bone to the hyoid cartilage, ligating the
superior thyroid artery.

Gussenbauer makes an incision from the ear to the greater cornu of the
hyoid. Finding the posterior belly of the digastric, the parts beneath and
back of it are divided into the maxillary region.

Weil and Mikulicz make an incision three and a fifth inches long behind
the ascending ramus of the inferior maxillary bone, including the parotid
gland if necessary. The facial nerve should be spared. The cut is continued
along the lower border of the body of the jaw, a double ligature being thrown
around the lingual and facial arteries.

Langenbeck, in 1879, opened the pharynx by making an incision beginning
midway between the symphysis and angle of the jaw and running downward
and outward to the thyroid cartilage ; the incision was deepened, and bleeding
prevented by tying the vessels before they were cut; if necessary, the hyoid
attachments of the stylo-hyoid and digastric were divided.

Cheever incises along the lower border of the body of the jaw, and saws
through the inferior maxilla in front of the masseter. The hyoid muscles are
divided, the bony fragments are pulled apart, and the tonsil is pushed out-
ward from the pharynx.

Kuester makes an incision beginning at the corner of the mouth, carried
back obliquely in front of the insertion of the masseter and thence to the
sterno-mastoid. The bone is sawed in the direction of this incision.

Langenbeck divides the cheek through its entire thickness downward and
backward from the angle of the mouth to the lower border of the jaw in front
of the masseter muscle ; from this point the incision curves backward under
the jaw to the sterno-mastoid. The jaw is sawn through in the direction of
the incision.

The Treatment of Club-foot.

Heinekes's method of treating club-foot is presented by Graser (Bcilag.
turn Centmlhlatt j'iir CMntrg., No. 24, 1888) as completely successful in the
most marked cases.

Briefly, the method consists in forcible reduction of the deformity, and
fixation by means of a plaster bandage. Section of the tendo Achillis is
condemned as removing an important aid in the correction of supination
and adduction. The lirst dressing may accomplish very little; subsequently
the tissues are more yielding and distinct progress is made by each manipu-
lation. The treatment lasts from six months to a year and a half, according
to the difficulty of the case, and is only completed when, on standing without
the bandage, the foot rests in complete pronation and dorsal flexion. When
this stage is reached further treatment is superfluous.

OTOLOGY. 533

OTOLOGY.

UNDER THE CHARGE OF

CHARLES H. BURNETT, M.D.,

B OF OTOLOGY IN THB PHILADELPHIA POLYCLINIC AND COLLEGE FOB GRADUATE* IN MEDICINE, ETC.

Syphilis of the Auricle, of the Middle Ear, and of the
Internal Ear.

Dr. Jones (-S7. Louis Courier of Medicine, April, 1888) gives the following
history of a case : A woman, thirty years old, complained of pain in the right
ear. There were also diminution of hearing, and general redness of the
membrana tympani. The voice was hoarse, and the entire velum palati deep
red. A large cicatrix surrounded the external auditory meatus, reaching to
the tragus, the anti tragus, and part of the concha, while the auricle in general
was considerably deformed. Three months later the patient presented her-
self with an ulceration ten days old, occupying in the left auricle a position
similar to that in the right ear. The ulcer had irregular edges, and the carti-
lage, which was exposed, showed a number of superficial abrasions, which
looked as though made with a punch. She complained of pain in her ear,
pulsating tinnitus, autophony, and facial neuralgia on the left side. Three
days later the left ear became suddenly and absolutely deaf. The diagnosis
of syphilis was confirmed by the appearance of a double perforation in the
velum palati in the course of a few days.

Foreign Bodies in the Ear.

Bezold (Berliner kUnische Wochenschrift , July 2, 1888) formulates the
following conclusions regarding the management of foreign bodies which
have become impacted in the ear.

1. The removal of foreign bodies from the tympanic cavity by the way of
the auditory canal, regardless of the swelling of the walls of the auditory
canal and of the distention of vegetable matter, may be an impossibility from
the position assumed by the foreign substance.

2. In such cases the state of the hearing is a valuable diagnostic guide ; for
example :

(a) If the existence of great hardnesss of hearing, or absolute deafness,
warrants the conclusion that a recent injury to the foot-plate of the stapes
has occurred, then the removal of the foreign body by means of exsection of
the posterior wall of the bony auditory canal, if removal is impossible in any
more conservative manner, becomes a vital indication, since the purulent
inflammation almost surely attendant upon the pressure of the foreign body
in this place will find its way through the opening in the oval window into
the labyrinth, and thence by the aquseductus cochlea? and the porus acusticus
internus to the meninges of the brain.

(6) If. however, much hearing remains, which would indicate that the foot-
plate of the stapes is intact, endeavors may be made, if the foreign substance

YOL. 96, NO 5. — NOVEMBER, 18S8. 35

534 PROGRESS OF MEDICAL SCIENCE.

is a fruit seed, to extract its watery parts by means of instillations of glycerine,
alcohol, and ether. Also forcible injections of water through the Eustachian
tube, which often succeed, may be tried, especially if we can still feel that
the foreign body is movable by means of a probe.

3. If, in a case of foreign body in the middle ear, whether any hearing is
present or not, in addition to purulency of the middle ear, there are local
symptoms of inflammation in the neighborhood of the irritant substance,
especially in the mastoid, an expectant treatment is no longer advisable (cold,
extraction of blood, etc.) as in simple suppurations, but instant opening of
the antrum is indicated.

4. The endeavor to remove the foreign body immediately after the opera-
tion, which consists in removing the outer mastoid wall and then the posterior
osseous wall of the auditory canal as far as the drum cavity, by means of
hammer and chisel, is justifiable; and in the case of children at least, in the
early years of life, nothing more than precaution against rapidly developed
brain inflammation.

Syphilitic Ulcer of the External Auditory Canal.

Dr. Skjelderup, of Christiania {Archiv fur Ohrenheilkunde., Bd. 27, Aug.
1888), gives the history of the case of an elderly man who presented in the
left auditory canal a linear ulcer, the size of a pea, with infiltrated edges, dirty,
pus-covered base, which the patient said had come from his picking a small
furuncle in the ear. There was no pain in the ulcer, but a little smarting.
After the use of mercurial ointment the ulcer enlarged. Some lymphatic
glands beneath the auricle became swollen, but no other glands were then
affected. The fauces were healthy, and all specific infection was denied by
the patient. Under further use of mercurial treatment, with applications of
nitrate of silver, the ulcer steadily enlarged. The diagnosis was: Rodent
ulcer; and the treatment consisted now in excision of the ulcer and the swollen
glands ; healing by first intention. Three months later there appeared faucial
and nasal syphilis, with characteristic ulceration on the posterior pharyngeal
wall. Large doses of iodide of potash produced a cure without any relapse.

The writer recommends the use of iodide of potassium in cases of ulceration
of doubtful origin.

Suppuration of the Middle Ear with Facial Paralysis am>
Elimination of the Cochlea.

I>i:. II. Ftt&Ut (iSboraSMftjQ Mel. Times, April, 1888) gives an account of"
the esse <>f a man, twenty-four years old. who had suffered lor many years
with :m otorrheas in his left ear, when he suddenly experienced a painful
swelling in the mastoid, with attacks of vertigo, becoming more frequent,
and facial paralysis on the left side. Trephining (he mastoid to tin- depth of
two and a half centimetres showed complete churnation of the bone. Later
a fistula formed at the Upper part of the auditory eanal, and gave issue to a
small piece of hone in which it was easy to recognize the course of the facial
Berre. Some months later there was removed from the same fistula the entire
cochlea. Alter this the discharge soon ceased.

OTOLOGY. 535

Otitis Media Hemorrhagica in a Child.

Dr. Thomas Barr (British Med. Journal, April 28, 1888) gives an account
of the occurrence of this unusual disease in a girl nine and a half years
old. She was attacked with malaria, insomnia, etc., and in the course of a
week there appeared an abundant suppuration from the left ear, above which
at the same time there appeared an inflammatory swelling. Two days later
there appeared in the middle of the night a considerable hemorrhage from the
ear. A physician then tamponed the external auditory canal with iodoform
on cotton, but as this caused a reflex cough, it was soon removed. The
hemorrhage occurred twice during the same day, and once on the next, but
did not reappear. The suppuration, however, continued for some days longer.
There was found an irregular perforation in the lower part of the membrana
tympani which cicatrized in a few days.

Influknce of Pilocarpine upon the Mucous Membrane of the

Tympanum.

Dr. W. Kosegarten, of Kiel, gives a most interesting account of his ex-
periments with the above-named drug (Archives of Otology, vol. xvii. No. 2,
June, 1888). Politzer was the first to recommend this agent in the treatment
of recent cases of exudative disease of the labyrinth, and in syphilis of the
same, where the process had not yet become chronic. But he limited its
application to recent affections, and discontinued its employment in the course
of a week if no good result ensued in that time. Kosegarten undertakes no
case which cannot submit to daily treatment for six weeks. He injects hypo-
dermatically one centigramme, and has watched the effect on the mucous tissue
of the tympanic cavity. A distinct redness is seen to come on thirteen
minutes after the injection, in some cases, and remain visible for forty
minute* ; then it fades away rapidly. In some cases the redness comes on
more slowly. It even appears that the secretion in the middle ear is increased
during the effect of the pilocarpine. It is held that this remedy acts both
upon the internal and middle ear disease. " By means of returning hyperaemia,
which may even cause exudation, there ensues pliability of the sclerosed
tissues and moistening and softening of adhesions, and in this way the
unyielding conducting apparatus again becomes more capable of vibrating;
when exudations had become deposited their absorption was brought about."
Politzer's want of success is attributed by Kosegarten to too short a trial of
the remedy, which can be efficient only when its action is long continued.

Menierk > Di-f.ase (Aural Vertigo).

Li < .E, of Berlin (Encydopctdie der gtsammten HeUkunde), thus marks out
the course of treatment he has found valuable in these cases: At the beginning,
especially in robust subjects, local bloodletting from the mastoid region by
means of Heurteloup's artificial leech, then prolonged rest in bed, seems to him
an indispensable condition in the proper treatment. As internal medications,
he employs chiefly subcutaneous injections of pilocarpine: ergot also may
be tried. Iodide of potash is useless. Sulphate of quinine is not advisable,
because it is liable to destroy hearing if given in large doses. It should not,

536 PROGRESS OF MEDICAL SCIENCE.

therefore, be used except as a last resort, and with full warning of its danger
being given to the patient. — Annates des Maladies de Foreille, etc., Aug. 1888.

A Case of Abscess in the Temporo-frontal Lobe of the Brain
produced by ear disease, ix which trephining and emptying
the Abscess produced entire Cure.

Dr. Thomas Barr, of Glasgow (Archives of Ofotoyy, vol. xviii., and Archiv
/. Ohrenh., Bd. 27, Aug. 1888), gives the following account of the above-
named disease : The patient, a boy, nine years old, previously strong and
healthy, had suffered for one year with a scanty, offensive discharge from the
right ear. Three months previous to the time Dr. Barr observed him, the
patient had suffered with pain in the affected ear and the corresponding side
of the face, attended with fever, and followed by vomiting and great somno-
lence. Several days later a chill was observed. At the time of the first
examination by Dr. Barr, the pain in the ear and head continued, as did also
the somnolence. There had been in all six chills ; the boy was greatly pros-
trated, and had a short cough, with purulent, offensive expectoration. The
examination of the ear revealed a perforation in the upper part of the mem-
brana tympani (probably in the flaccid membrane) from which a little puru-
lent discharge escaped. All signs of an acute process, or of retention of pus
in the ear, were wanting, and the mastoid process was only slightly sensitive
to very hard pressure, and externally it was normal in appearance. As
however, after a short pause, pain in the ear and head set in again, and the
somnolence became very marked, and a slight chill was experienced, Dr.
Barr opened the mastoid and removed a little purulent and cheesy matter.

The condition of the patient was not in the least improved by this operation.
The pains in the head, especially in the forehead, continued, and percussion of
the right temporal region was very painful ; the somnolence was still marked.
A slight ptosis of the right eye, and a trace of paralysis of the right side of the
face, became apparent ; the veins of the right half of the head were congested,
the right sterno-cleido-mastoid was stiff', and pressure behind the origin of
the sterno-cleido-mastoid muscle, where the vein comes out of the posterior
condyloid foramen, caused great pain. The general condition of the patient
was very poor, irregular muscular trembling was apparent throughout the
entire body, pulse slow, weak, and intermittent. From the right ear there
suddenly came a copious discharge of pus, very offensive in odor, which seemed
to denote that a communication had been formed between the abscess in the
brain and the organ of hearing. The chances for a good result from an opera-
tive opening of the abscess supposed to be in the temporal bone were in this
case the most unfavorable; still, as herein lay the only possibility of saving
the patient, the operation was undertaken by Dr. Macewen at Dr. Barr s
request.

After complete disinfection of the ear and the region of the proposed ope-
ration, a disk half an inch in diameter was removed from the squamous por-
tion of the temporal bone at a point one and a half inches behind the centre
of the auditory canal. The slightly congested dura was incised, and into the
yellowish-red protruding brain substance, covered with the congested pia, an
aspirator needle was inserted in a direction forward, inward, and downward.

LARYNGOLOGY. 537

At a depth of three-quarters of an inch foul gas was found, and soon there-
after about two drachma of yellow, offensive pus were evacuated. The latter
continued to escape when more of the necrotic brain substance was removed.
In order to procure a thorough cleansing of the abscess a counter-opening
was made at the lower part of the skull, directly above the bony boundary of
the auditory canal, in the line of the petro-squamous suture. Through this
opening, and also in the reverse direction, the abscess cavity was washed out
by means of a solution of boric acid, and then drainage tubes, made of chicken
bone, were inserted. The region of the operation was then dusted with boric
acid, and bandaged with corrosive sublimate cotton. This dressing was re-
moved, on the average, once a week, and the drainage tube was shortened in
proportion to the granulation of the tissue, and finally omitted, the upper
one in five weeks. The result of the operation was most satisfactory. In the
first week the pulse became quieter, the face became fuller, the ptosis dis-
appeared, the psychical condition improved, and the weight of the body in-
creased. Granulation of the wounds occurred promptly; the lower closed
completely, the upper was protected by a piece of rubber bandage until the
osseous closure occurred. The otorrhcea ceased under the boric acid treat-
ment, leaving a dry perforation in the membrana tympani.

DISEASES OP THE LARYNX AND CONTIGUOUS
STRUCTURES.

UNDER THE CHARGE OP

J. SOLIS-COHEN, M.D.,

OF PHILADELPHIA.

Spasmodic Choreic Cough Cured with Spray of Methyl Chloride.

Dr. J. Garel {Annates des Mai. de Foreille, August, 1888) reports the case
of a girl, thirteen and a half years of age, who had had an almost continuous
choreic cough for two months. Topical applications with cocaine in ten per
cent, solution, only provoked fresh spasms and increased their intensity. A
strong spray of methyl chloride was played upon the back of the neck and
upper part of the spine, as well as upon the anterior portion of the neck.
During the process, an assistant made energetic frictions over the part to pre-
vent too deep an action on the tissues. Amelioration began the same night,
and gradually increased during two weeks, by which time the cure had become
permanent.

Laryngeal Chorea.

Prof. Nicola Tamburrixi takes occasion [Archiv BaBtmi di Laringologia,
io, 1888), in reporting a case, to question the accuracy of the opinion
which refers this affection to motor incoordination of central origin, and to
range himself with those who regard it as a sensory lesion producing a periph-
eral spasm and due to local hypenemia and hyperaesthesia.

538 PROGRESS OF MEDICAL SCIENCE.

Pseudo-polypus Laryngeal Phthisis.

Drs. A. Gougenheim and P. Tissier {Annates des Mai. de Poreilte, etc.,
July, 1888) describes a class of polypoid vegetations observed in young
subjects, especially in the first stages of tuberculosis, and independently ol
any other lesion in the larynx. They report one case in which tuberculous
dendritic growths were so extensive as to demand tracheotomy, and although
recurrences had been frequent, there was no evidence of pulmonary lesion as
late as ten years thereafter when the canula was definitively removed from
the trachea. These tumors are most frequent at or near the petiolus of the
epiglottis, the mesoarytenoid region, and the subglottic space. They are
distinct from the well-known similar formations which occur in connection
with tuberculous infiltrations and ulcerations.

Acute Stenosis of Larynx; Tracheotomy; Death from Shock.

Dr. A. Trifiletti reports (Archiv Italiani di Laringologia, Luglio, 1888)
a case of oedema of the epiglottis, with stridor and convulsive movements of
the larynx and trachea, in a boy eight and a half years old, with broncho-
pulmonary fever. Tracheotomy was performed, but the patient died some
twenty-eight or thirty hours afterward, without any apparent cause other
than shock.

Syphilis of the Larynx.

Dr. J. Garel records {Annates des Maladies de Poreille, et du Larynx, etc.,
June, 1888) an interesting case of specific perichondritis of the left arytenoid
cartilage, the symptoms of which simulated an acute oedema of the larynx ;
and which was complicated with a sessile fibromyoma, the size of a large
pea, situated at the anterior commissure of the glottis.

Dr. Charles Mauriac (Arch. gen. de Med., February, March, June,
1888) has contributed a most valuable and quite exhaustive article on
tertiary syphilis of the larynx. It is replete with references and with de-
tails of manifestations which are unusual. Considerable attention is given
to the laryngoplegias of syphilis and to the means of discriminating them
from similar lesions non-specific in orgin.

Gunshot Wound of Larynx

Dr. H iero Stoessel reports {Annates des Maladies de VoreiUe, et du Larynx,
etc., June, 1888) the case of a man whose larynx was accidentally penetrated
October 6, 1887, by a paper obturator from an old gun at five paces' distance.
The missile was immediately expelled by coughing; and then some fragments
of cartilage were extracted from tlie wound. A canula was inserted through
the wound. An attempt to remove the canula two days afterward was fol-
lowed by intense dyspnoea and cyanosis, and it had to be replaced A fresh
fragment of cartilage was removed at the same time. Respiration becoming
seriously embarrassed, he entered the clinical service of Prof. Weinlechner,
Vienna. Ho was aphonic. Both phases of respiration were slightly
stridulous. To the left of the median line there was a wound in the thyroid
cartilage, surrounded with excessive granulations. The glottis was irregu-

LARYNGOLOGY. 539

larly quadrilateral, and a whitish prominence projected into the larynx
ween the slightly tumefied arytenoid cartilages. Another prominence,
the size of a small haricot bean, was located at the anterior angle at the side
of the epiglottis. From the base of this second prominence, a reddish-gray
membrane stretched to the middle of the right vocal cord.

Tuberculous Tumors of the Larynx.
Db. Artur Hennig, of Konigsberg (Berliner klin. Woch., July 9, 1888),
describes and illustrates a rare example of multiple supraglottic tuberculous
tumors of the larynx in a man fifty-two years of age, who had been hoarse for
twelve years. One, the size of a filbert, occupied the left ventricular band;
one, the size of a pea, the right ventricular band. These were smooth, ovoidal
and sessile. A third neoplasm, which was dendritic and the size of a lentil,
occupied the posterior surface of the left arytenoid (supra-arytenoid ?) carti-
lage. In all other respects the laryngoscopy appearances were normal ; there
being no ulcerative, infiltrative or anaemic evidence of tuberculosis. These
tumors were removed with the thermocautery after splitting the larynx ;
precautionary tracheotomy having been performed as the preliminary feature.
The diagnosis of the nature of the tumors was based on microscopic exami-
nation by Professor Baumgarten, after their excision. Severe fever set in
suddenly five weeks after the operation ; unconsciousness followed, and the
patient died in forty-eight hours.

Laryngectomy.
Dr. William Gardner, of Melbourne, reports (The Medical Preu, July
V, 1888) a case of total extirpation of the larynx on October 2, 1887, for
epithelioma in a male subject, sixty-two years of age, who, on December
2~>th, was able to go about the streets without pain or cough and with increase
in weight. The report is probably a preliminary one, inasmuch as the only
reference to the extent of the disease is, that " laryngoscoptc examination
showed a small ulcer below the left vocal cord."

I i.< erative Lesions of Soft Palate and Larynx in Enteric Fever.

Dr. St. v. Vamopy (Wien. klin. Woch., August 2 and 16, 1888) describes
two interesting cases of ulceration of the soft palate, one of which is illustrated,
and discusses the subject in an excellent summary. He concludes that the
ulcerative throat lesions in enteric fever are due to the action of the special
virus destructive to the glands of the throat, and the same as to the analogous
glands in the intestine, and that these ulcers are not, as has been thought, due
to pressure and position, or what are known as ulcers from decubitus.

On the Anatomy of the Epiglottis.

Mr. Mayo Collier ijoum. of Lar. et Rhin., June, 1888) finds that the
anatomical descriptions in the books are in several points incorrect. He de-
nies that the glosso-epiglottic ligaments have any connection with the tongue,
except by continuity of mucous membrane. He denies the existence of a
thyrohyoid membrane. All that he finds is a thin fascia lining the inferior
aspect of the thyrohyoid muscle and covering over a quantity of areolar

540 PROGRESS OF MEDICAL SCIENCE.

tissue and fat. This fascia is coextensive with and intimately attached to
the hyoid origin of the thyrohyoid muscle, a well-marked interval existing
between the two portions on the opposite side.

A New Diagnostic Feature in Paralysis of the Dilators
of the Glottis.

In an article on the pathology of dilatation of the glottis [Deutsch. med.
Wochenschr., June 28th, etseq.) Dr. Ed. Aronsohn, of Berlin, directs attention
to the state of the pulse in cases of paralyses of the posterior crico-arytenoid
muscles. He finds that the pulse is accelerated in all cases due to disease in
the nerve supply. He believes that it may be taken for granted that in those
cases in which there is no acceleration of the pulse there is an organic disease
behind the point at which the recurrent nerve leaves the pneumogastric, a
myopathic paralysis of the posterior crico arytenoid muscles or an adductor
contracture. The acceleration of the pulse is either the expression of irrita-
tion of the sympathetic nerve, or the evidence of paralysis of the cardiac
branches of the pneumogastric nerve. These cardiac branches come from the
inner and motor root of the spinal accessory nerve, just as the inferior laryn-
geal nerve does ; and, therefore, when the cardiac branches of the accessory
nerve are paralyzed, simultaneous disturbances of innervation of the muscu-
lature of the glottis must also be attributed to paralysis of the laryngeal
branches of the same nerve.

Treatment of Carcinomatous Stricture of the (Esophagus.

M. A. F. Plicque presents (Annates de Mai. de Forei/te et du Larynx,
August, 1888) a critical review of the methods of treatment.

I. Dilatation by catheterization does not give durable results, for as soon as
sounds sufficiently large are passed, spasm or inflammation ensues, which
prevents further introduction of instruments, and counteracts all the benefits
painfully acquired. Sometimes it excites absolute impossibility to swallow-
where glutition of liquids had been practicable. Furthermore, cases are only
too numerous in which, when the tissues are soft, the catheter penetrates the
aorta, the bronchi, or the mediastinum. Finally, the favorable results occa-
sionally attained are usually due to the concurrence of exceptional conditions.

II. Gitxtrostonnj. A patient who can swallow liquids has nothing to gain
from gastrostomy ; and if the operation is performed when aphagia is com-
plete, death cannot be postponed beyond a few days. The operation lias but
a moral palliative value. Of 145 gastrostomies collated by Lagrange, the
mean duration of life was but 19 days. In 36 only, was life prolonged more
than a month ; and in 24 out of 25 of these, of which the details are given,
the operation had been performed before the state of aphagia had been
reached. Plicque concludes with Lagrange, that gastrostomy is useless if
performed prematurely, and too dangeroOJ when performed late.

III. Th' />'-ri/i<tiirftf refrn/ioi) of catheter* in the (esophagus is the most desir-
able method of treatment, although it is yet in doubt whether short t

are preferable to the longer ones. One great objection, however, is the inse-
eurity of the -ilk strings attached to facilitate extraction; but it is to be hoped
th it this dilhculty will soon be overcome by some mechanical contrivance.

OBSTETRICS. 541

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

VISITING OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL.

Obstetric Practice at the Boston Lying-in Hospital.

Boarhmax {Boston Med'val and Surgical Journal, No. 9, 1888) reports three
months' practice in this hospital, a total of one hundred and twelve cases.
Strict antisepsis is practised, and no septic death occurred. But one child
died after birth. The complications most frequently met with were success-
fully treated; a case of multiple fibroids, and three cases requiring crani-
otomy were especially interesting. In addition to means usually employed,
an intra-uterine douche of hot vinegar was found efficient as a haemostatic.

The Practical Results of Modern Obstetrics.

Fischel ( ( 'entrallilaft fur G>//i<"tko/»f/ie, Nos. 32 and 33, 1888) reviews the
diminution in puerperal mortality resulting from antisepsis, and urges the
importance of a better understanding of its technique by practitioners.

The mortality rates of the large maternities of Austria, Germany, Russia,
and Bohemia show a diminution of, in round numbers, 50 per cent, from
sepsis; the death-rate from this cause having been 1.3 per cent, from 1874 to
1884, and since 1884, 0.72 per cent, to 0.42 per cent. An estimate of the
mortality in private practice on the Continent is difficult, because midwives
commonly deliver normal cases, and only serious complications are brought
to the physician. This mortality is probably much greater than that of the
maternities.

Fischel urges that physicians be thoroughly drilled in innocuous antisepsis ;
and that maternities be so managed as to give the fullest advantages for
practical study. That this may be safely done with proper discipline is illus-
trated by the fact that during the winter of 1886-1887 no case of septic
infection occurred in Fischel's wards, although the best possible opportunities
are given to students to examine cases.

[The superiority of asepsis obtained by the proper use of antiseptics, over
antiseptics applied frequently to the patient, as formerly practised, is very
suggestive. This usage prevails in the best American maternities, whose
septic death-rate is less than one per cent. Fischel's suggestions regarding
the improvement of practitioners and students are very pertinent to America.
Public sentiment should be educated to permit proper clinical instriutinn,
and the education of the average practitioner should include a practical
knowledge of antiseptics and their proper use. — Ed.]

Obstetric Practice at Marburg.
Ahlfeld (Deutsche med. Wochenschrift, Nos. 23, 24, 25, 27 and 28, 1888)
reports the work in his clinic for a year; the following are points worthy of
note:

542 PROGRESS OF MEDICAL SCIENCE.

In 308 labors the forceps were used but 3 times. The " birth stool," two
chairs placed side by side, in contact posteriorly, but separated anteriorly,
was used ; the patient being placed over the triangular opening. As soon as
the head is born, she is placed in bed. This birth stool is used in cases in
which forceps are ordinarily employed. There were numerous cases of con-
tracted pelvis. Cephalic version was done three times; podalic, three;
combined version twice.

Cr6de's method of placental expression was employed three times, manual
removal of the placenta once. The patient usually lay undisturbed one hour
and a half after the child was born ; the bladder was emptied and gentle
pressure from above sufficed to expel the placenta ; post-partum hemorrhage
was very rare. None of the mothers confined died; of 308, 226 had no
elevation of temperature.

Ahlfeld cleanses gently the child's eyes, nostrils, and mouth as soon M the
head is born. If the child does not breathe, it is placed in a warm bath. If
no improvement follows in about ten minutes, the child is wrapped in hot
flannel and the trachea catheterized to remove mucus ; air is not blown into
the lungs. Gentle friction, especially over the chest, is of the greatest value.
Ahlfeld does not believe that more forcible measures are admissible; his
experience with swinging the child by the shoulders and blowing air into the
lungs has caused him to reject them.

Obstetric Methods in Prague.

Morton (New York Medical Journal, No. 26, 1888) describes the methods
of the clinic at Prague, as instituted by Professor Breisky, now in Vienna.

Bichloride of mercury is the antiseptic most used ; carbolic acid is used for
instruments and for intrauterine injections. [The use of bichloride solution
for intrauterine injections resulted in a fatal intoxication, after which it was
abandoned. — Ed.] Instruments are sterilized in flame, when possible. Cath-
eters are filled with lead in the space between the tip and the eye to prevent
septic accumulation.

Rigid antisepsis of practitioner and patient is enforced. Vaginal douches
are not given after labor in normal cases. Iodoform is used in the uterus
and vagina,

The uterus is not irrigated unless operated upon, or evidence of infection
exists. The breasts are uniformly treated before and after labor with bark
acid, 4 per cent, solution.

Nitrate of silver, 2 per cent., is used as a prophylactic against ophthalmia,
hiarrhcea and indigestion in infants are treated by washing out the stomach
with a small catheter, rabbet tube and funnel, as advised by Epstein. The
child is given white of egg and water fur twenty-four boon afterward. In-
struction b given in the hospital; septic mortality ui - per loon.

[The wards ami their arrangement are excellent, and the uniform courtesy
of Dr. Klcischmann (in charge) renders the clinic a place of interest ami
tore to foreigners. — Ed.]

Tin: Use of Bichloridi: Of Mkrcury in Obstitbiob,

BLAjrO (Lyon MHicale, No. 34, 1888) concludes, from numerous clinical
observations, that solutions of l • 4000 and 1 : 5000 should be generally used.

OBSTETRICS. 543

It' 1 : 8000 is given by intra-uterine injection, it should be followed by the
injection of carbolic acid two or three per cent. The danger of absorption,
from the anatomical condition of the parts, is undoubted. Contraindication^
to the Me of the bichloride are anaemia and disease of the kidneys.

OB8TETRIC ANTISEP8I8 FOR NUR8ES.

Creoe and Winckel, in the Text-book for M'nluivvx, published by the
Government of Saxony, advise the following rules for nurses : They should
carry with them four ounces of dissolved carbolic acid, nail brushes, soap,
sterilized cotton and carbolized vaseline two per cent. The hands and fore-
arms should be cleansed with soap, warm water, nail brush, and five per cent,
or two per cent, warm carbolic solution. The external genitals of the patient
are cleansed with soap, water, and two per cent, carbolic solution ; for vaginal
douches, fissures in the vagina and fissured nipples two per cent, carbolic acid
is used. The strictest prohibitions are enjoined against bringing soiled clothes
in contact with the patient.

If sepsis occurs, the midwife who delivered the case should immediately
transfer it to another nurse, under a physician's orders; she herself must
thoroughly cleanse her body, clothing, and instruments, and deliver no other
case for at least five days. Vaginal examinations must be as infrequent as
possible, and she must report to the sanitary authorities every two days for
a week, that they may know that she infects no other patient. Should other
cases arise in her practice within thirty days, she must be quarantined for
two weeks. — Deutsche med. Wochen*<-hrift, No. 32., 1888.

Interesting Cases of Twin Pregnancy.

Riviere {Archives de Tocofogie, No. 7, 1888) reports a case of twin preg-
nancy in which one foetus and placenta occupied the upper half, and the other
foetus and placenta the lower half of the uterus. A membranous partition
rated the two. The placenta of the lower ovum was attached as low as
the inferior segment, but as the head was very small, dilatation sufficient to
produce placental hemorrhage did not occur.

Two cases are also described in which one foetus was killed by an injury to
the mother, while the other survived. A case of twin pregnancy with obsti-
nate vomiting is also reported, in which labor was induced. Riviere believes
that over-distention of the uterus producing exaggerated nervous reflexes is
the cause of obstinate vomiting.

Compressing Forceps.

At the last meeting of the British Medical Association Dr. Mori: H a iit.n,
in the "Address upon Obstetrics," expressed his belief in the forceps as pref-
erable to destructive instruments, and superseding them by reason of its coin-
pressing power.

He had devised a short forceps which allowed the foetal scalp to protrude
freely through its fenestra when compression is made ; and also long forceps
armed with a compressing rod and screw similar to those used in a cranioclast.
In addition, the latter forceps is supplied with a pair of detachable traction
rods, allowing the exercise of traction at any angle. — British Medical Journal,
August 18, 1888.

544 PROGRESS OF MEDICAL SCIENCE.

Fracture of the Symphysis Pubis during Labor.

Faux {Bulletin de la SociU'e Obst'etricale de Paris, No. 8, 1888) reports the
case of a primipara, aged twenty-five, to whom he was summoned during her
difficult labor, the presentation being right occipito-posterior. The pelvis
was slightly contracted in its antero-posterior diameter.

Tarnier's forceps were applied, and traction made for intervals during an
hour. As the head reached the perineum, crepitus was distinctly perceived
by the operator. Tarnier's fv-rceps slipping, Pajot's were substituted, and
labor terminated. At the moment when the head was born the crepitus was
again perceived. The head of the child was of normal size, and showed no
marks of violence ; the child was dead, Faux thought from the long duration
of labor (forty-eight hours). The mother had moderate post-partum hemor-
rhage. On catheterizing her the fracture was plainly felt, and the subpubic
tissues were bruised and cedematous. Faux had no opportunity to examine
the patient's pelvis before labor. No especial malformation was evident. She
made a speedy recovery.

Cesarean Section at the Present Time.

Among the most interesting recent publications upon this subject is that
of LEOPOLD (Der Kaisersrhm'tf und Seine Stelhing zur Kiui-Aliehen Friihgeburt
Wendung und Perforation bei Engem Becken, Stuttgart, Enke, 1888). The
section upon induced labor is written by Korn, who analyzes 45 cases; 35 of
which recovered without a rise of temperature; 9 had slight febrile disturb-
ance ; 1 died of sepsis. In symmetrically contracted pelves with conjugata vera
of three inches, and pelves whose conjugata vera only is contracted (to two
and three-quarters inches), induction of labor is indicated, from the thirty-
second to thirty-sixth week.

Lohmann contributes a chapter upon version. 107 cases are reported ; the
mortality from sepsis is nil ; the indications are a foetus of moderate size, at
term, in a pelvis whose dimensions are the same as those mentioned by Korn.

Prager reports 71 craniotomies, with maternal mortality, from sepsis, nil.
When the time for the induction of labor has passed, and the indications for
other methods are wanting, craniotomy gives most excellent results.

Leopold writes upon Csesarean section. He thinks the time has not yet
come for abandoning craniotomy upon the living child ; in a portion of the
cases it may be rejected ; in the greater number it cannot be discarded.

The indications for Ca'sarean section are as follows: When nature fails to
deliver a living child whose development is so great that version and forceps
cannot be employed ; and the consent of friends and relatives can be obtained.

The conditions essential for success are: 1. The mother must be in good
condition as regards strength, and not advanced in labor; early rupture of
the membranes is not an advantage. 2. She must not be already infected
by frequent vaginal examinations and efforts at delivery which lacerate the
tissues. 8. The heart-sounds of the child must be normal in strength and
frequency. 4. Operator end seebtents must understand antisepsis and the

plan of operation.

The maternal mortality after Caesarean section during four years at Dresden

has heeii >.»'. p,r cent., 4.8 per cent, from sepsis. Eighty-seven per cent, of

OBSTETRICS. 545

the children so delivered were saved. An improved method of suturing the
uterus is needed, so that conception afterward shall not be rendered more
difficult or dangerous.

The indications for Porro's operation are: 1. Infection of the body of the
uterus. 2. Stenosis of the cervix and vagina by tumors not connected with
the uterus. 3. In cases of myomata in the body of the uterus. 4. In preg-
nancy in the occluded half of a uterus bicornis. 5. In rupture of the uterus,
when the child lives, in a contracted pelvis. 6. In retained placenta, with
sepsis, other treatment failing. 7. In osteomalacia. — Munehener med. Wochen-
»chri/t, No. 30, 1888.

Successful Cesarean Section for an Unusually Contracted

Pelvis.

Delassus {Annates de Gynecologie, September 1888) reports the case of a
woman aged thirty-nine, who had been healthy except for a remarkable de-
formity, upon whom he performed Csesarean section at term. The deformity
was found chiefly in the superior strait ; the left half of the pelvis was abnor-
mally roomy, the other diameters were less altered than the appearance of
deformity indicated. Elaborate measurements were made ; the anteropos-
terior diameter of the pelvic inlet was two and three-quarters inches. A
marked spinal curvature existed ; the general appearance of the patient being
that of a person in whom sitting had forced the sacrum and the pelvis down-
ward and forward. Rachitis was not present, and the most reasonable ex-
planation afforded by the history and data of the case was that in early life
the patient had suffered from myelitis in the lumbar cord, which had for a
long time necessitated the sitting posture during the period of bony growth.
The weight of the vertebral column had driven the sacrum forward, causing
it also to rotate partially upon its axis.

Csesarean section was made after the modern method. The interrupted
catgut suture was used. The uterine incision was prolonged downward
further than usual, resulting in a minute uterine fistula, which was afterward
healed by using a drainage tube. Ergotin was given hypodermatically before
the operation. Aside from a rapid pulse (120) and constipation, the recovery
was uneventful.

INTRA-LIGAMENTOU8 Tubal Pregnancy; Laparotomy; Recovery of
Mother and Child.

Eastman reports (American Journal of Obstetrics, September, 1888) the case
of a patient whose abdomen contained a tumor extending from the pubes to
the vicinity of the liver. The uterus was normal ; the breasts not enlarged ;
no foetal heart was heard. Menstruation had ceased ; paroxysms of intense
pain, and increasing abdominal enlargement were present.

Abdominal section revealed tubal pregnancy in the right broad ligament.
The sac was opened, and the child extracted without detaching the placenta.
The tube was then ligated and removed with the placenta in mass. A clamp
was placed upon the neck of the sac, and the pedicle so formed was quilted
with silk (cobbler's stitch). The peritoneal cavity was washed out with hot
water three times, and a glass drainage tube was employed. Mother and child
made a speedy, uninterrupted recovery. The growth and development of

546 PROGRESS OF MEDICAL SCIENCE.

the child have proceeded normally. It was between the seventh and eighth
month when delivered.

TUBO-ABDOMINAL PREGNANCY ; LAPAROTOMY ; RECOVERY.

Meyer {Zei(«chrift fur Geburtshiilfe und Gynakologie, Band 15, Heft 1)
reports the case of a primigravida aged twenty-seven, who presented the
usual signs of pregnancy. During several coitions she felt abdominal pain,
from which she recovered ; these pains became more severe, and were finally
followed by collapse. In this condition, when examined by Meyer, a boggy
tumor was found at the left of the uterus, and a diagnosis of extra-uterine
pregnancy, with rupture of the sac, was made. The patient was removed to
a hospital for further treatment.

For the following three or four weeks her general condition improved.
Examination under chloroform confirmed the diagnosis, and led to the belief
that the foetus was developing, in spite of the rupture of the sac; laparotomy
was accordingly done. Free hemorrhage followed; the foetus was rapidly
extracted ; the placental tissue formed a tumor as large as a man's fist, con-
nected with the uterus by a pedicle two inches wide and four inches long,
composed chiefly of the thickened Fallopian tube. The ovary was about three
and a half inches from the placenta, toward the median line. The pedicle
was ligated with silk just on the inner side of the ovary and severed, and the
placenta removed. A pseudo-membrane had been formed by the haematocele,
which bled profusely. Irrigation with two and a half quarts three per cent.
boric acid solution at a temperature of 112° F. failed to check the hemor-
rhage; a sack of iodoform gauze was introduced which was evenly stuffed
with four strips of iodoform gauze, thus equally tamponing the cavity; the
upper two-thirds of the wound was closed, the gauze strips and silk ligature
used in making the sack were brought out at the lower angle of the wound,
and a heavy antiseptic dressing applied.

The wound was dressed three days after operation, and the gauze removed ;
the sack was removed two days later. An attempt to close the wound was
followed by retention of fluid, which necessitated a drainage tube for a few
days.

The patient recovered perfectly. The foetus was nineteen weeks old, and
deformed, but was not macerated. Examination of the tube revealed follicular
salpingitis with partial occlusion at the abdominal extremity, where the ovum
lodged; this Meyer thinks may have been secondary, not primary, to the
lodgement of the ovum. The patient had had dysmenorrhea, which OM
after the operation. Meyer regards the case as probably primary tubo-
abdorninal pregnancy. [ For Breisky's interesting and somewhat similar <
the reader is referred to the Journal for February, issx, p. L'0<>.— Ed.]

1 in I >r.\ i i OPMSB r «>i rHK l'i..v< i:nta.

Frommel, at the recent meeting of the German Society for Gynecology

nekmtr med. Wochcuxrln v .. L888), stated the results of exp
nifiit- -tinlics in the development of the placenta as follows:

The ovum forms, when lodged in the uterus, a crypt in the uterine wall :
the contents of this crypt or pocket become the placenta. The villi of tin

OBSTETRICS. B4T

chorion are formed in the proliferation of the <.U*«-i<iua. A ring of vessels
forms beneath the blastoderm of the ovum which are derived from an artery.
The glands of the decidua disappear as the placenta forms, and take no part
in forming the placenta ; the ovum puts forth vascular processes of epithe-
lium. The allantois is formed upon the endochorion and sends loops of
vessels into the villi of the chorion ; the endochorion forms from the amnion.
From the vessels just described bloodvessels pass through the decidua deep
into the uterine wall. Maternal and foetal blood come into such close contact
that both communicate freely.

Leopold and Wiener supported the view that the villi of the chorion
are lodged within the bloodvessels.

An Unusual Form of Placental Retention.

LANGE (Zeiischriff fur Geburlshulfe und Gyitilkologie, Band 15, Heft 1), in
638 cases of operative obstetrics, has encountered retention of the placenta 21
times. Two of these cases were caused by abnormally low tension in the
abdomen following rapid labor. Cred6's method fails in these cases. The
placenta is found lying in the lower uterine segment, and is readily removed
by the hand ; an audible rush of air accompanies the delivery. The accumu-
lation of blood usually found behind the placenta is wanting. Lange believes
that the placenta is separated by the last uterine contraction which expels
the child ; its expulsion is accomplished by the abdominal muscles and the
weight of the blood-clot formed behind it. When the abdominal muscles are
paretic with negative intra-abdominal tension and the blood-clot is lacking,
this form of placental retention occurs. Retention of urine may be similarly
caused (Schwarz).

Reliable Signs of Parturition Remaining after Recovery.

Rode {Norditkt medicinskt. Arkiv., Band 20, No. 6, 1888) considers a dilated,
somewhat gaping vulva; scars of varying length in the vagina; and altera-
tions in the shape and structure of the uterus reliable evidence, medico-legal
if needed, of previous parturition.

In women who have not borne children the external os uteri may be round
or oval. In parous women it is a transverse slit, whose border is fissured.
With parous women the distance between the external and internal os uteri
is from nine-tenths to three-quarters of an inch; in multiparous this measure-
ment is proportional to the length of the corpus uteri.

But little reliance can be placed upon the breasts ; scars in the areola about
the nipple are to be noted.

The Relation between Puerperal Psychoses and Septic Infection

Hansen (Zlittehrjfl fim G'burt.*hulfe und Gynakologic, Band 15, Heft 1)
has examined 49 cases of psychic disturbance occurring during the puer-
perium ; in 42 of them he found septic infection, in varying degrees, present.
In 40 of these cases the mental disturbance was that of hallucinati-'ii> ; in the
remaining 2 mania and hallucinations were observed. Of the 7 remaining
cases: 1 was acute tuberculosis; 4 had been epileptic or eclamptic; 1 had
hallucinations which varied greatly in character; 1 had melancholia.

548 PROGRESS OF MEDICAL SCIENCE.

Hansen concludes that the majority of cases of puerperal psychoses are
caused by septic infection or eclampsia ; when in the early weeks of the puer-
peral period a psychosis characterized by acute hallucinations develops, with-
out the presence of any other infection and without a previous eclampsia, the
diagnosis of puerperal septic infection is justified even in the absence of fever
and other symptoms ordinarily present. The mortality in the 49 cases reported
was 26.5 per cent.

Inflammation of the Salivary Glands following Labor.

Acker (American Journal of Obxtetrics, September, 1888) reports the case
of a multipara who suffered from inflammation of the salivary glands after
normal labor. The attack persisted for seven days ; suppuration did not occur.
The puerperal period was entirely without other complications. No history
of mumps or septic infection was obtainable.

The Treatment of Puerperal Ischuria.

Schatz ( Wiener med. Presse, No. 26, 1888) advises dilatation of the urethra,
to admit the little finger, in these cases. The procedure is not exceedingly
painful and gives good results. Mild cases usually yield to catheterization.

Battlehner advises local applications of cocaine, 10 per cent, solution.

Skutsch accustoms his patients, before labor or operations, to urinate
while lying in bed; he is thus obliged to have recourse to catheterization
very rarely.

Effects of Non- oxygenation of the Maternal Blood upon

the fostus.

Charpentier and Butte (Nouvelles Archives a" Obstetrique et de Gynecolo'jie,
No. 8, 1888) report the results of experiments upon pregnant rabbits to de-
termine the effect produced by non-oxygenation of the maternal blood upon
the foetus. By one method the animal was immersed in warm saline solution,
the abdomen and uterus opened, and the changes in the placental circulation
observed. A second method consisted in ascertaining the condition of the
foBtus after the mother had succumbed to the loss of oxygen.

It was found that when the oxygen of the maternal blood is gradually
lessened, the fetus perishes before the mother. When the oxygen of the
maternal blood is suddenly and markedly lessened, the mother dies first, the
foetus surviving several minutes. If oxygen in considerable quantities was
abstracted, the mother surviving, the foetus died after some time.

The inhalation of carbonic acid gas, in quantity not sufficient seriously to
affect the mother, does not affect the life of the foetus.

Note to Contributors. — All communications intended for insertion in the Original
Deport m. Tit c.f tliis .Journal are only received with the distinct understanding that they
are contributed exclusively to this Journal for publication. Gentlemen favoring us with
their nommankatioai are considered to be bound in honor to a strict observance of this
inidrrstnnding.

Liberal compensation is made for articles used. Extra copies, in pamphlet form, if
■ l.-ind. will !»«• furnished to authors in lieu of compensation, provided the request for
them be written on the manuscript.

THE

AMERICAN JOURNAL

OF THE MEDICAL SCIENCES,

DECEMBER, 1888.

FATTY OVERGROWTH OF THE HEART.1
By F. Forchheimer, M.D.,

PROFESSOR OF PHYSIOLOGY AMD CLINICAL DISEASES OF CHILDREN IN THE MEDICAL COLLEGE OF OHIO,

CINCINNATI.

It appears almost needless to state that fatty heart means two different
firms of pathological changes — the one an infiltration, the other a de-
generation. The object of this paper is to discuss the former, fatty over-
growth of the heart.

In looking through the literature upon this subject, it is remarkable
how many names have been given to this affection ; thus, Gowers (Rey-
nolds's System of Medicine, vol. iv. p. 760) calls the affection fatty over-
growth, and then gives the synonyms as follows: fatty infiltration
(Rokitansky) ; fatty overgrowth, fatty hypertrophy (Quain) ; adipose
cardiaque, surcharge graisseuse, obesite du coeur (French writers), to
which can be added lipomatosis, polysarcia cordis, cor adiposum of the
Germans, not to mention the German names themselves, which are used
by the latter. The term " fatty heart " is certainly not sufficiently
distinctive, as others (Pepper) have already pointed out, and, as we are
dealing with an affection clinical principally in its importance, it would
be well to unite upon one term, so that the confusion which now exists
might be done away with. The name chosen is one of two given by
Richard Quain (Medico- Chirurg. Trans., 1850, p. 121 etseq.), the author
who has written if not the best, certainly the most memorable article
upon the subject ; it seems to express as much as need be expressed. If
we chose to retain short terms, fatty heart might be retained for the
degenerative process, and fat heart for the infiltrative.

i Read before the Association of American Physicians, Washington, 1888.

VOL. 96, NO. 6.— DECEMBER, 1888.

550 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

So far as the historical development is concerned, it certainly is a fact
that Hippocrates (the all-knowing), Galen among the very old, and
Morgagni, Senac, Haller, Lancisi, and others among those preceding the
present modern school, have referred to the subject in one way or
another. Laennec and Corvisart spoke of both fatty degeneration and
infiltration, but made nothing of the condition from a clinical stand-
point. For the first appreciation of this condition, not only at the post-
mortem table but also at the bedside, we must turn to the Dublin school,
represented by Cheyne (1818), Stokes a little further on, and Kennedy,
who is very diffuse (1849-50). By far the best and most acute essay
written about this time (183b) is that of Latham {Lectures on Subjects
connected with Clinical Medicine, published by the New Sydenham
Society, 1876, pp. 326-328, vol. i.), which we will have occasion to study
a little more carefully. He makes a distinct division of fatty heart into
obesity and degeneration, describes correctly the changes undergone by
the muscular tissue, gives an excellent though very brief account of the
symptoms, and places an estimate upon the possibility of a diagnosis
which, certainly, seems very sound. Next, chronologically, comes the
essay of Richard Quain, accompanied by a table of cases which forms
the basis of a table published by Hayden (Diseases of the Heart and
Aorta, Philadelphia, 1875), and is, in every respect, the most important
contribution to the subject in the English language.

During all this time the Germans had been quiet, from a clinical
standpoint, and it is not until 1878 that we find Leyden beginning his
work (Berl. klin. M'ochenschrift), which he continued and completed in 1882
(Ztschrft.f. klin. Med.). Oertel (Hdbch. d. allgemeinen Therapie, vol. iv.,
1884), who has made special studies and reduced the treatment to a
method, claims that he began his work nine years before publication and,
although priority as far as German literature goes must be denied him,
he, with Leyden, has done more to call the atteution of the profession
to fatty overgrowth of the heart than any one else.

The large handbooks which have been published in our days (Virchow,
Ziemssen, Pepper) all devote more or less space to the subject and it is
a special gratification to see that Prof. Osier, in the discussion of the sub-
iect in Pepper's Cyclopaedia, has held to the strict line of demarcation
between fat and fatty heart. Most modern text-books refer to the subject,
but, as a rule, they discuss both conditions together. There have been hut
two complete tables published (Quain and Hayden). It was found wry
difficult to decide upon proper cases, and, for the sake of accuracy, only
such cases have been included in which the diagnosis was beyond doubt.
A great many of the older cases, therefore, were rejected on account of
incomplete reports, and other cases, from which incomplete deductions
only can be drawn, were also omitted.

FORCHHEIMER, FATTY OVERGROWTH OF HEART. 551

Etiology. — Whatever causes obesity may cause fatty overgrowth of
the heart. The two conditions are absolutely connected together. When
authors speak of the occurrence of a fat heart in phthisis or cancer, it
may he a process of fatty degeneration, or of true fatty overgrowth ; in
the latter case due to obesity, however. Quain states that it is more
common in males than females, but quotes Bizot, who found it more com-
mon in females. The latter, according to Quain, found 9 fat hearts in
14 fat females, and 14 fat hearts in 29 thin females; but, in the language
of Quain, Bizot's investigations apply to " a mere greater or less quan-
tity of fat.'* In the table appended, 88 cases were males and 34 females.
As far as age is concerned, it may occur at almost any time of life.
Thus Kisch gives 36V per cent, from thirty-five to fifty years, 39} per
cent, from sixteen years (the youngest) to middle age, 24 per cent, in
persons from fifty to sixty years. As far as these statistics go, then, it
would seem that 76 per cent, occur before fifty years, and only 24 per
cent, after this time. In the collection of cases, 122 in all, in 5 of which
no age is given, 59 per cent, were below sixty years of age, 41 per cent,
above.

Occupation plays a very important role in the production of heart
symptoms with obesity; a man who has been active up to thirty-five or
forty, and then leads a life of idleness combined with fat-producing con-
ditions, is apt to suffer with fat heart. This may explain the great
preponderance of the affection in males ; females, as a rule, continue
with their vocations or do not have occasion to change their habits
from intense activity to physical idleness as often as men. The abuse
of alcohol or the taking of great quantities of fluid by a fat individual,
certainly predisposes to fat heart under proper conditions ; in two of my
own cases, fat heart has developed in the bookkeepers of large breweries.
These men consumed enormous quantities of beer daily (from thirty to
BXty glasses) ; their only occupation consisted in keeping their accounts,
and when the time for exercise in the evening came they were physically
unable to take it. As a result, fat accumulated, and the heart became
affected. It is remarkable that, although the men who are engaged in
working in the breweries drink just as much beer, they are not affected
by this form of heart trouble. This alone goes to show that it takes
more than obesity to produce fat heart, for brewers, as a rule, are
above average weight.

As will be shown further on, all fat people are in danger of having
not only their hearts surrounded but also invaded by fat. But gi
two very obese persons, it is a problem why one should have heart symp-
toms and another not. The influence of sex, occupation, and alcohol
has been referred to above ; everything causing heart strain or irregular
activity of the heart may predispose to the further development of fat
heart. In this category of causes may be enumerated excessive use of

552 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

tobacco, coffee or tea, great and frequent excitement. Frequently patients
with fat heart are in a condition bordering on neurasthenia, frequently
their whole character becomes changed from good nature to irritability ;
but it seems impossible to determine whether we are dealing with cause
and effect, or vice versa. It is not uncommon to find a man who has
been obese since his twentieth or twenty-fifth year, and has carried his
fat without symptoms of any sort, manifesting signs of fat heart after
he has gone through prolonged trouble — the loss of a fortune in one
of my cases, and the struggle to get another. The symptoms here will
develop gradually and, combined with a neurasthenic condition, there
will be present all the signs of fat heart.

Pathology. — Leyden has divided the disease into two classes : 1, fatty
growth around the heart ; 2, fatty infiltration of the heart. The latter
class he subdivides into two ; one without and the other with arterio-
sclerosis. It has seemed unnecessary to me to make the subdivision, as
we can consider arterio-sclerosis a complication, but hardly one of the
prominent features of fat heart. It will be seen from the table that
only 39 cases had atheromatous deposits, yet, as additional proof of the
point raised, it will be remembered that this table is composed principally
of cases which have been observed upon the post-mortem table as well
as clinically. It has been impossible to find a very great number of
cases, which have recovered, on record — these, manifestly, being the ones
which ought to decide the question. We might, perhaps with more
reason, make a subdivision of fat heart with bronchitis or dropsy, for
both of these conditions, although complications, are found in nearly all
well-marked cases at a certain stage of the disease.

From the standpoint of pathology, modern medicine has done very
little to add to our knowledge concerning the relation fat bears to the
heart. It seems, furthermore, that it is not the pathology that int< ■:
us, especially in our present state of knowledge, as the objective
signs, certainly for one state of the diseased condition, are hardly
characteristic for any particular change in the heart substance. Quail)
states that Rokitansky in his Handbuch d. path. Anatomie, ed. 1842, has
described three forms of fatty heart: 1, fat in excess upon the surface,
2, fat among the muscles, in excess; and 3, fatty degeneration I have
failed ti> find this in the edition of 1856). Sir .lames Paget was the first
to introduce these views to the English public in his scries of lectures
published in the Med. Gazette for 1847, and the divisions made by
EtoldU&tky arc, practically, those made by Leyden as quoted before.

Of the first form, fat in excess upon and around the heart, little
be said in this connection. We find it in obese subjects, and it com
simply of an increase of fat in the connective tissue of the mediastinum,
and the various layers of the pericardium. Upon the external surface
of the heart the fat is found in excess wherever there is connective

FORCHHEIMER, FATTY OVERGROWTH OF HEART. 553

tissue, and this especially around the superficial bloodvessels to begin
with. As a result, we have the fat increased in the sulci of the heart
first, then over the ventricles; the right ventricle is affected more than
the left on account of the greater number of superficial bloodvessels
Lying upon it. There is usually quite a large deposit of fat at the apex,
and, frequently, a fringe extending along the right border of the right
ventricle. A great many cases will be found in which the heart is so
buried in fat that none of the muscular tissue can be seen. In these
cases, however, it is doubtful whether we are dealing with a pure case of
fat heart of the first degree, as the condition of the myocardium decides
this question.

As far as can be seen from the incomplete record, no microscopical
examinations having been made, it seems that some cases are recorded
in which the myocardium remained perfectly healthy, although invested
by fat. From a pathological standpoint we are dealing, as a rule, with
a case of the second class, when the fat around the heart becomes devel-
oped to such an enormous quantity as to invade the myocardium.
The line of demarcation between a normal and an abnormal deposit is
one that cannot be drawn with mathematical accuracy. In all the
cases investigated by modern methods, it seems to be abnormal when it
interferes with the functions of the myocardium. Again, this is a point
which cannot in all instances be determined with certainty by post-
mortem investigation, thus giving additional force to Leyden's argument
for the acceptance of the condition as a clinical and not a pathological
entity. Yet the decision of pathological increase of fat cannot be diffi-
cult for the experienced pathologist in the majority of cases. The
essential part of the change consists in the intrusion of fat upon the
muscular substance of the heart : the results are atrophy of the muscular
fibres and fatty degeneration.

The first change is the one seen most commonly ; it is due to pressure
by fat, and, as a rule, is associated with a " distortion " of the muscular
fibres. It is remarkable how little fatty degeneration is found in these
cases, a fact to which Quain already calls attention, and Leyden insists
upon with great force. The latter author goes so far as to state that
wherever fatty degeneration of muscle is found, it is due to general and
not to local causes. It would be remarkable to admit that the anaemia
which must follow the development of fat in such quantities around the
bloodvessels could not produce fatty degeneration ; but opposed to this
is the fact that fatty degeneration was found to a very limited degree
in the five cases examined in this direction by Leyden, one of which
was also investigated by Grawitz. More extended observation is de-
sirable, especially as to the relation of those parts degenerated and the
quantity of fat around the bloodvessels supplying those parts. Upon
macroscopic examination, the myocardium will be found normal in size

554 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

in some instances, but always less resistant and usually softened, easily
torn, and of a pale brownish color. Cases have been described in which
the fat has given its own color to the muscular substance. The fat
makes its inroad from without, so that we see the muscles under the
pericardium invaded most, and those under the endocardium least, the
fat invasion extending through the whole substance in very severe
cases. The papillary muscles would naturally be attacked, on account
of their connection with the outer layers of muscular fibres, but this
does not seem to be as frequent as was once supposed.

The mechanism of the changes that follow is a very simple matter.
The substitution of fat for the hardest and most resistant muscle in the
body leads to dilatation, best marked where there is most fat ; some-
times hypertrophy follows, sometimes there is myocarditis. Rupture of
the heart takes place where the process has lasted for a long time, and
where it is well developed. In the cases collected, this took place in 25
out of 122 : most frequently upon the left side of the heart (in 18), upon
the right side in 3 cases, once in the ventricular, once in the auricular
septum. In 2 cases locality is not mentioned. It is a remarkable fact
that valvular lesions are quite uncommon, for in the whole number of
cases collected only 16 had lesions of the valves, which were, for the
most part, due to processes of a different nature. As the result of cir-
culatory troubles, we see the usual changes which take place in a great
many different forms of heart disease. The lungs are congested, their
bloodvessels dilated, and their whole volume sometimes increased. In
all probability this is due to the stasis which occurs in them, whether
the circulation be disturbed from the right or the left side of the heart.

Symptoms. — The first class of cases presents few or no symptoms that
could be called characteristic. The patient, like all fat people, is short
of wind, cannot stoop often without losing his breath ; whilst walking or
running will produce dyspnoea. The same can be said for great or pro-
longed excitement. Physical examination may or may not reveal any-
thing abnormal. If the patient be very fat, percussion will give only
an approximate idea of the size of the heart, otherwise, the area of
heart dulness is found increased on account of fat upon the pericardium.
Palpation frequently reveals a diffuse heart impulse, but it is normal
just as frequently, although it may be feeble. Auscultation simply
shows normal heart sounds. The pulse in these cases is strong, neither
rapid nor slow. If an analysis of these symptoms be made, we will find
that we must base our diagnosis upon attacks of dyspnoea and enlarge-
ment of the heart dulness in a fat person. The first symptom can be
explained without taking the heart into consideration as cause; the
breathing space is smaller than normal, on account of accumulation of
fat within the thorai and the abdomen, and this is especially the case
when the patient bends over. Furthermore, if we look to the heart, tat

FORCHHEIMER, FATTY OVERGROWTH OF HEART. 555

people have more blood, absolutely, than lean ones (Recklinghausen,
Oertel | ; therefore, any slight exertion will give the heart in a fat subject
more work than it can do with comfort, the size of the heart not being
increased with general obesity. The second symptom, enlargement of
heart dulness, may, in individual cases, be well enough developed, but
it seems to me very risky to base a diagnosis upon simple enlargement
of the heart dulness in a fat patient, not to say anything of the difficulties
experienced in detecting this enlargement. At best, then, it seems jus-
tifiable only, to suspect fat growth around the heart.

In the second class of cases we have a clinical picture which is more
distinctive. The patient comes to the physician and complains of symp-
toms that are easily referred to some affection of the heart. He has
been fat for years, and has been bearing his fat perfectly well until a
comparatively recent time, when he complains of one or another symp-
tom, which leaves no doubt as to where the cause of trouble lies. The
least exertion causes dyspnoea; he will be waked up at night, especially
after a full meal, by an attack of dyspnoea, or he finds it difficult to get
to sleep, after having retired, on account of violent and painful palpita-
tion. Or he has more or less well-defined attacks of angina pectoris, at
one time represented by violent pains in one or both arms, without
dyspnoea, at another, attended by the most pronounced difficulty in
breathing. Again, the complaint may be that the patient is suddenly
attacked by asthma, of cardiac nature, or that he has cardiac asthma
almost constantly. In some cases, short attacks of a semicomatose or
apoplectic character are complained of. Rhexis of bloodvessels accom-
panied by true apoplectic seizures takes place, when atheromatous pro-

M> are associated with fat heart. It will be seen that there is
nothing absolutely characteristic in these symptoms, except that they
are the result of weak heart or of degenerate bloodvessels.

As far as the subjective signs are concerned, it is not necessary to
point out here that fat in the myocardium will not produce symptoms
differing from those of the heart weakened or dilated from other causes.
Neither does it seem a fit place to add that a dilated or weak heart will
be followed by the same symptoms, as far as circulatory disturbances
go, whether the cause be myocarditis, aneurism of the heart, or fatty
overgrowth. At best, we must base our diagnosis upon a combination
of signs, as it is impossible to depend upon the subjective symptoms
when the diagnosis can be made. The subjective symptoms vary enor-
mously, as can be best illustrated by the two following cases :

Case I. — Y. Z., male, aged thirty-seven years ; weight 227 pounds ;
size five feet eleven inches. Family history good. The man had been
an actor from his twenty-second to his thirty-fourth year of life. Before
that, studied at a German university. Within the last three years has
been bookkeeper and partner in a large liquor store ; states that he does

556 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

not drink much daily, but occasionally has to drink too much. Has had
all the diseases of childhood ; muscular rheumatism after Franco-Prus-
sian War, in which he was an officer; had gonorrhoea, but never had
syphilis. During the time of his activity as an actor he never weighed
more than 165 pounds, until 1881, when he began to gain, so that in
1883 he weighed 230 pounds. He was able, by means of exercise, to
reduce himself, but never lower than 200 pounds. Since he has changed
his occupation he has gained steadily, and now complains of restless
nights, and of sleeplessness during the day and night. Occasionally he
has pain in both arms, especially in the left one, which sometimes
becomes very acute, radiating from the region of the heart into the
shoulder and from there to the hand ; but not accompanied by dyspnoea.
When he stoops or eats a full meal the blood rushes to his head and he
feels very much oppressed over the chest. His eating has so much
effect upon his breathing that, latterly, in order to satisfy his appetite,
which, he claims, is not very good, he has been forced to eat more fre-
quently than before, but much less at a time. Has palpitation of the
heart when he lies down, and cannot walk or run as he formerly did
without bringing on an attack of palpitation and violent dyspnoea. In
these attacks he says that his chest feels as if it would burst, and could
not on account of being surrounded by a hoop of iron. Examination
reveals heart impulse diffuse and weak in the left mammary line ; heart
dulness extending to one inch beyond the right of the sternum, to the
mammary line on the left and to the level of the second rib upon the
sternum. Heart sounds clear but muffled. Pulse ranging from 90 to
100, weak and easily compressible, but perfectly regular.

This is a specimen of the beginning of trouble. The case following
is one of a much severer type. (In narrating both these cases, much
has been omitted which has not seemed essential.)

Case II. — X. Y., male, aged forty years, weight 190 pounds, size five
feet eight inches. Father died of apoplexy, mother of diabetes mellitus.
Consulted me .May 29, 1887. States he has been stout since his
twenty-fifth year. Had left him a large fortune by his father, which he
lost on Wall Street under circumstances involving very much litigation,
and leaving him a complete bankrupt. This occurred several years
before he noticed anything of his present ailment, except that he had
become very nervous. He ascribed this to worry and anxiety, and to
his continued want of success in being able to provide for hi* family.
Drinks moderately now, but has drank too much. Smok< rely

— fifteen to twenty cigars a day. Has had gonorrhoea, chills and fever,
erysipelas (1875), and is a hay fever subject In September of 1886
he first noticed the beginning of his present illness. This consisted of a
spasmodic contraction about the chest, accompanied by dyspnoea when
he walked fast. The attacks became more violent, the pain extending
especially to the left arm, and coming on without the provocation of
raise. Thinking about anything interesting or exciting at all. will
provoke an attack. At first these attacks lasted but a few minutes, but
now they last much longer. On May "J, 1887, had an attack coming on
at niffht, asthma, associated with pain in the head and chest, which left
as suddenly as it eame. The next night he wa- kept awake all night by
a similar attack, which left him sore the next morning. He consulted

FORCHHEIMER, FATTY OVERGROWTH OF HEART. 557

a physician, who prescribed a solution of nitroglycerine, which seemed
partially to control these attack.-. Upon examination, the apex beat
found outside of the mammary line, dulness upon percussion began
here, but did not extend to the right of the sternum, nor higher than
normal. Auscultation showed a systolic bruit at the apex, very soft, a
change in the accent of the first and second sound, and an accentuation
erf the second pulmonary tone. The pulse was small, but not too fast.
This patient wad treated, sent to Marienbad eventually because he could
not be completely controlled at home, and upon his return the follow
note was made : The heart reveals nothing abnormal except a slight
indistinctness of the first sound at the apex. Accentuation of second
pulmonary sound disappeared. Patient has lost over thirty pounds in
weight, and feels perfectly well.

Upon examining the heart, we are enabled in individual cases to arrive
at a positive conclusion; this is even admitted by Rosenbach (Ziemssen's
Real Encyclopcedie, vol. vi. p. 484), who, in general, denies the possibility
of a positive diagnosis. As has been pointed out before, percussion in a
very tat individual does not give satisfactory results; we can say, in
general terms, that the area of dulness is increased as it was in the first
form, sometimes more definitely to one or the other side. In reexamin-
ing some of my cases, I have availed myself of auscultatory percussion,
and find that, even in very fat people, the heart dulness presents a
decidedly different outline from the ordinary when examined in this w ay.
My experience in this direction, however, has been so very limited that
I would not dare to say anything about the absolute value of this method.

By palpation, the heart impulse is found to be very diffuse, and, in
some instances, it cannot be felt at all, it matters not in what position
the patient be placed, whether lying down, standing up, or leaning for-
ward. Auscultation reveals something abnormal in every case. At the
apex the first sound is changed in one way or another, almost the first
manifestation being that the trochanc rhythm is altered. The first sound
becomes weaker and less accentuated, and, in some cases, has disappeared
entirely (Hardy, Bull, de VAcad. de Medecine, 1882, p. 236). It has
also been stated that the first sound has been reduplicated, so that the
valvular and the muscular sound could be distinguished, the one from
the other. A low bruit is sometimes heard with the first sound, which
has been attributed by authors to different causes. Curschmann (Deutsche*
Archivf. /din. med., 1874, p. 93) describes a case of fatty infiltration of
the heart, in which the papillary muscles were infiltrated as well as the
rest of the heart ; in this case a bruit was heard toward the end of the
illness, with the first sound at the apex, no accentuation of second sound
at the pulmonary, so that Curschmann calls the bruit hsemic. On the
other hand, Orate Wiener med. Wochenschrift, 1864) relates a case in
which there was decided infiltration of the papillary muscle, yet no
bruit was heard. In all the other cases which I have looked into, no

558 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

bruit was present when the papillary muscles were affected, although it
would seem that, theoretically, a bruit could be produced by degenera-
tion of the papillary muscle, which is also admitted by Schroetter (Ziems-
sen's Handbuch, vol. i. p. 236), yet, practically, this does not occur. The
cause for this is probably to be found in the fact that a sufficient number
of muscular fibres are left to prevent the mitral or tricuspid valves from
becoming insufficient. The bruit is not of a valvular origin, because, as
has been pointed out before, valvular lesions are very rare in fat heart ;
and secondly, the other physical lesions do not correspond with a val-
vular lesion. The bruit which is heard must, I take it, be due either to
the irregular contraction of the muscular fibres of the heart, or it must
be hsemic in its origin. It would lead too far to discuss the question,
but it seems to me to be the same bruit which is heard in those cases of
chorea in which we are able to establish neither the existence of a heart
lesion nor anaemia

An accentuation of the second pulmonary sound is sometimes heard at
the base of the heart, especially in those cases in which the left side of
the heart is dilated and weakened ; but this is by no means of sufficient
frequency to lay stress upon. Yet its presence can be of importance
from a diagnostic standpoint. In the second case I have reported, there
were present all the physical evidences of a mitral regurgitation, yet if
percussion could be relied upon, and this seemed to be the case, as the
patient was not too fat, there was enlargement of the left side of the
heart, and none in the right, which naturally precluded the diagnosis of
mitral regurgitation. Thus, then, and it is unnecessary to adduce other
illustrations, there may be an incongruity of physical evidences which
alone leads to the proper diagnosis in a fat person The pulse differs from
the weak and rapid to the weak and slow, irregular, or intermittent, or the
latter combined with rapidity. It is almost characteristic of the condi-
tion to have a large, apparently healthy and robust individual present
himself with the pulse of a child. If the sphygmograph be used, it will
be found that the tracings vary enormously. Kisch divides the cases
into four groups: 364; per cent, have a pulsus tardus which is sometimes
anacrotic, in 32 per cent, the pulse is subdicrotic or dicrotic, in 24 per
cent, there is increase of arterial tension (arterio-sclerosis >, and in 7f per
cent, there is arhythmia, from an intermittent to an irregular tracing.
A slight amount of exercise brings out the true character of the pulse,
sometimes changing the tracing so that it is hardly recognizable as
Doming from the same patient.

Examination of the other organs may or may not reveal anything
abnormal ; this depends entirely upon the heart. It has seemed to me,
however, that an examination of the urine was necessary in every case,
for two reasons: it gives us a knowledge of the degree of heart affection
(albuminuria existing or not) ; and, secondly, we get an idea of the met ah-

FoRCHHEIMER, FATTY OVERGROWTH OF HEART.

olisni of the body (which we can get by no single method of examina-
tion, and which is invaluable an far at treatment ie ooaeenied from a
easeful, quantitative ai well as qualitative urinalysis. Examination of
the urine is of the greatest importance.

Diagnosis. — A great deal has been said and written on the subject of
diagnosis of fat heart, from absolute negations of its possibility in any
case, to positive enthusiasm of its recognition in every instance. From
all that has been said, it will be seen that the fact that there is a change
in the myocardium is the only diagnosis we are justified in arriving at.
If we now take into consideration that we are dealing with a fat person,
the chances are that the case is one of fatty overgrowth of the heart.
But we are not justified in excluding degenerative changes in the myo-
cardium— these are frequently found in the same individual. A decision
may be arrived at in the individual case if we weigh all the symptoms
carefully ; and, again, it may be almost impossible to make a differential
diagnosis between fatty overgrowth and a valvular lesion. Latham
(Lectures, XXVI., p. 328, New Sydenham Society, 1876) has expressed
our position very aptly : " we are able, during life, to conjecture a fat
heart with such strength of probability that we almost know it."

Prognosis depends very much upon the form that we are dealing with.
Cases of the first class are to be looked after, because they will eventu-
ally develop into the more serious second form. It is a problem still to
In solved, why some fat people escape fat heart, and why others who are
by no means so fat will suffer. It is within the observation of every one
that persons may be enormously heavy, and yet have no heart symptoms
whatsoever. It is impossible to determine what percentage of fat people
suffer from heart complication. Kisch, in the introduction of his book
on " Die Fettleibigkeit," (1888), says that he has seen over 10,000 cases
of obesity in an experience of twenty-five years at Marienbad. Further
l>age 91) he speaks of having in latter years utilized sphygmographic
tracings of 700 obese persons " in whom the diagnosis of fatty overgrowth
of the heart could be made with probability bordering on certainty."
The phrase " in den letzten Jahren," in late years, causes one to conclude
that he has seen more than 700 cases of fatty heart, so that there is no
certainty in utilizing his figures. This much can be stated with certainty,
that any obese person is in danger of fatty overgrowth of the heart, and
that the weight does not form a positive index as to the chances of its
occurrence. For the individual, the amount of involvement of the heart
must be the principal factor as to prognostication, although the age,
general condition, and form of obesity must not be lost sight of.

Treatment. — The treatment of fat heart is the same as that of obesity.
In the majority of instances we remove all that there is of the disease
when we remove the fat ; the muscles of the heart resume their natural
functions, and the patient is relieved. There are a great many ways of

560 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

reducing a patient's weight (I presume it is a part of modern medical
science to call these methods, and by various names). There is the Bant-
ing (Harvey), the Ebstein, the Oertel, the Schweninger method, and
several others. The principles upon which they are based are identical,
absolute reduction of food taken in twenty-four hours, and plenty of
exercise. To this Oertel and Schweninger add reduction in quantity of
fluids introduced. Ebstein prefers the fats to the starchy and saccharine
foods, but allows mixed diet like all the others, with the exception of
Banting (Harvey), who prescribes an almost exclusively albuminous
diet. As there is no doubt that all of these methods have succeeded,
so there can be no doubt that the principles upon which they are based
are correct. It is necessary to add, only, that there is an indication
for each one or none of these methods ; in other words, that every case
must be treated as an individual one, and that the so-called methods can
give us nothing more than general outlines, which must be filled up.

The treatment by saline cathartics is a very valuable adjunct — these
may be in the form of mineral waters or medicaments, to be used, how-
ever, in suitable cases. The two latest works which have been written
(Oertel and Kisch) take opposite sides on the question of benefit from
Marienbad, Carlsbad, etc. The true state of affairs will probably be
found in the middle. Oertel, who lays most stress upon the collection
of fluid in the system, and the disturbance of hydrostatic equilibrium,
warns physicians at bathing resorts not to accept these patients ; yet the
action of saline cathartics is to withdraw fluids from the system. Kisch,
who finds a fine difference between Marienbad and Carlsbad, to the
enormous advantage of Marienbad, advises the use of sweat-baths, which
withdraw water. It would be folly to send an anaemic obese patient to
Marienbad, just as it would be extremely risky to put a patient with
thin and dilated heart-walls through Oertel's plan.

A great many remedies have also been recommended, some with
specific properties, some without them ; some of them are very useful,
such as arsenic, iron, but none will do the work without the proper diet.
One thing seems to be agreed upon by all observers: that whatever
treatment is used, must be continued for some time. This will be illus-
trated by the following case, of which I give the outlines.

Case III.— March 2, 1879. A. R., aged fifty-five, male : weight 298

pounds; size five feet ten inches. Comes on account of a heavy cold
which he says he has contracted. Has been coughing for several years.
lias been a saloon-keeper for ten years; before that, unsuccessful mer-
chant. Began to gain weight after changing occupation. Drinks not
less than twenty, sometimes as high as forty glasses of beer in twenty-
four hours (from one and a half to three gallons). Takes more or less
wine and whiskey. Karelv goes out of his saloon, takes no exercise
whatsoever. Finds it Impossible to get to his sleeping apartment on the
■econd floor without resting three or four times on account of difficulty

FORCHHEIMER, FATTY OVERGROWTH OF HEART. 561

in breathing and palpitation. Cannot walk any distance without stop-
ping to recover his breath. Becomes dizzy when he stoops, etc. I
animation shows enlargement of right side of the heart, no heart impulse,
first sound at apex very weak, accentuation of second pulmonary tones
and evidences of a general bronchial catarrh. Pulse rerj weak, rapid,
but regular. Urine contains traces of albumen.

Treatment consists in reduction of Said taken into the system, exer-
and Carlsbad salts. It was not necessary to order diet, because the
man ate very little. The patient gradually reduced the quantity of
liquid he was taking to three small glasses of cognac a day, and as he
did this his appetite began to improve, so that a diet list was made for
him, quite generous, mixed, and limited as to quantity only. He began
by walking a given distance without resting (one-half square), then was
told to increase this, and to do this continually, so that after two weeks
he was able, without fatigue, to walk twenty times as far as when he
first started. In the course of this time he had lost fifteen pounds, and
all his symptoms were improving. He was then told to climb slight ele-
vations, of which there are a great many in Cincinnati, and after three
months of treatment he climbed some quite high hills which surround
the city. After six months of treatment he had reduced himself to 245
pounds (loss of 53 pounds), and was feeling perfectly well. He had to
give up his saloon for financial reasons, started in another occupation,
and did well. For two years (until 1881) he kept up with his treat-
ment, occasionally gaining in weight a little, and then making extra-
ordinary efforts to reduce himself, in which he always succeeded.

About this time his new venture began to fail him, he grew careless,
began to drink again, and gradually regained almost all that he had
lost (weighing 285 pounds). On July 17th he was attacked with an
apoplectic seizure, coma set in, and in a few days he died. A post-
mortem was not permitted.

Oertel's method, briefly stated, consists in the exercising of the heart,
reducing the quantity of fluid in the system, and a diet. Exercise of
the heart is accomplished by causing the patient to climb hills of various
grades, the distances being marked off and under the control of a phy-
sician. By means of this exercise the following is accomplished :
strengthening of the myocardium and increase of its function, since this
muscle behaves like any other muscle of the body ; secondly, an increase
of blood to the right side of the heart ; thirdly, a flushing of the pul-
monary circulation ; and, lastly, increase of blood in the left side of the
heart and in the systemic circulation under normal circumstances. In
order to accomplish all this without danger to the patient, it is necessary
to pre-suppose certain preexisting conditions. The first thing to be
taken into consideration is that the arteries are in healthy condition, so
that the resistance to the emptying of blood from the left side of the
heart is not great enough to cause damage, such as producing dilatation
of the left ventricle, etc. When atheroma is present, therefore, Oertel's
plan cannot be utilized.

Secondly, before beginning the method, it is necessary to determine,

562 FORCHHEIMER, FATTY OVERGROWTH OF HEART.

if possible, what is the condition of the myocardium. Our limitation
of knowledge comes in here — it is impossible to say positively what we
are dealing with — hypertrophy of the heart, with or without dilatation,
dilatation alone, myocarditic changes, or what not. In this, then, comes
the risk of using the method. Up to date, not a single case has been
reported in which harm has been done by the plan. From theoretical
considerations, a great many cases ought to exist ; they have not oc-
curred, so that the future must decide whether or no the danger is as
great as we suppose. Every case of fat heart (extensive atheromatous
cases excepted) ought to be treated with this method, or some modifica-
tion of it (Bad Nauheim). The following argument is conclusive to
me: if nothing be done, in bad cases, the patient will be lost, and if this
method be used, he can be saved (Oertel says all cases without atheroma .
The first trials are to be made under the supervision of the physician,
and it is astonishing how soon the heart, and with it the general circu-
lation (dilatation of the arteries and increase in pressure), become accus-
tomed to the additional labor. In the discussion at Wiesbaden, Lich-
theim laid especial stress upon the danger of producing stretching
(Dehnung) of the ventricular wall. Yet it must be remembered that
increased resistance is aimed at in this treatment of fatty overgrowth, as
well as an increase of intracardiac pressure. This is accomplished by
strengthening of the myocardium, by exercise, and the bringing together
of the muscular fibres by means of the removal of fat. That the method
has done this has been proven by several cases.

The dietetic treatment which Oertel uses belongs to the subject of
treatment of obesity, in which we are only indirectly interested. As
for the hydrodynamic treatment of myopathic heart trouble in general,
as proposed by Oertel, it applies with great force to some cases of fat
heart. Although it has been proven by Schroetter and Lichtheim that
withdrawal of water does not increase the density of the blood very
much (2-3.4), and although Bamberger has shown that fat people do
not suffer from serous plethora, yet, the abstinence or withdrawal of
water in some fat people is a principle not to be overlooked. What-
ever the effect upon the system may be, which is disputable ground,
reduction in the quantity of fluid is sufficient to cause loss of weight in
a great many fat people. As far, then, as fat heart is concerned,
Oertel's plan is the best in suitable cases ; it has its limitations, it iv<[iiires
great care; but until some definite charges beyond theoretical objection!
are brought up against it, it should be tried in all those cases in which
no resistance is offered on the part of the arteries or the lungs.

The medicinal treatment is the same as that of any other trouble of
the myocardium digitalis, nitroglycerine, strophantus, etc.). I might
add that, in my limited experience, morphia is badly borne by these

FORCHHEIMER, FATTY OVERGROWTH OF HEART. 563

patients and that a great deal can be accomplished by valerian or some
of its preparations.

Total number of cases reported :

Qmhl

Males 88

Females 34

Total

Age.

Below 10
10-20
20-30
30-40
40-50
50-60
60-70

Over 70

■ hna,

Per cent.

.85

5.12

11.96+

16.23+

24.78+

30.77+

10.24+

117

Actire.

Retired.

Total

Occupation :

Males

Atheroma of arteries:

Aorta 21

Coronary 14

Other arteries 4

Total 39

Rupture of heart :
Left side
Right side
Ventricular septum
Auricular septum .
Locality not stated
Rupture near aorta

Total

18
8

1
1
1

Division of superior vena cava 1

Lesion in valves 16

TOL. 96, HO. 6.— DBCKMBEft, 1888.

564 LLOYD, LEAVER, TUMOR OF SPINE.

A CASE OF TUMOR OF THE CERVICAL REGION OF THE SPINE.
OPERATION AND DEATH.1

By James Hekdrie Lloyd, M.D.,

VISITING PHYSICIAN TO THE NERVOUS AND INSANE DEPARTMENT OF THE PHILADELPHIA HOSPITAL ;
IN8TBUCTOR IN ELECTRO-THERAPEUTICS IN THE UNIVERSITY OF PENNSYLVANIA j

AND

John B. Deaver, M.D.,

SURGEON TO THE PHILADELPHIA, ST. MARY'S, AND GERMAN HOSPITALS, AND DEMONSTRATOR OF
ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA.

Medical Report by Dr. Lloyd.

This patient was admitted into the writer's wards at the Philadelphia
Hospital as a simple case of hemiplegia of several months' duration, and
as such cases abound there, and as she did not present obtrusively any
special symptoms, several days elapsed before she was prominently
brought to my notice. The resident physician, Dr. Talley, then called
my attention to the fact that the patient had stiffness of the neck, pain on
moving the parts, and a slight prominence on the left side of the spine at
about the level of the third cervical vertebra. The following history
was elicited :

Catharine W., aged about forty-five years, native of Germany. No
history of tubercle, alcoholism, or syphilis obtainable. Four months
before her admission to the hospital she said that she had a burning pain
in her head. About this time the left leg became weak and she gradu-
ally lost power in it. The left arm then began to lose power.. It was
not stated by the patient very accurately how long after the leg the arm
became paretic, but it was a period of some weeks. As in the case of the
leg, the paresis of the arm was gradual in its approach until the Limb
was quite paralyzed. There was not, and never had been, any paresis
of the face or tongue. For some time (period not accurately stated)
before the appearance of any paretic symptoms the patient had noticed
a slight swelling or tumor on the back of the neck immediately to the
left of the median line, and corresponding to the third cervical vertebra.
Tlic neck was stiff. During sleep she said that her arm "jerked."

Her condition at the time of the first examination was as follows : The
left arm was paretic and slightly wasted (?). The left leg was para-
lyzed, slightly spastic, and gave well-marked ankle clonus ami rectus
clonus. The patellar reflexes were very inueh exaggerated in both legs.
The muscles of the affected limbs gave no changes to electric excitation.
The right arm and leg were positively normal in their motor functions
to the most rigid tests, but there was slight ankle clonus on that side,
not nearly so great as on the affected, or left, side. There was no ami s-
thesia anywhere. Mindful that this was a case in which crossed anes-
thesia and paresis might exist, I examined the patients right sound)

> Read before the American Neurological Association, nt the meeting of the Congress of American
Physicians and Surgeons, Washington, D. C, September, 1888.

LLOYD, DEAVER, TUMOR OF SPINK. 565

arm and leg with the greatest care again and again, but no tests demon-
it-fittd any hiss of sensation. The same was true of the left (affected)
side. There were no subjective symptoms of altered sensibility (paraes-
t beni . ii' >r to heat or pain. There was no paralysis of any facial, ocular,
or lingual muscles of either side, nor any alteration of sensation in these
The pupillary reflexes to light and accommodation were normal.
bad a marked swelling on the back of the neck, referred to above.
It was slightly sensitive to pressure, and seemed very deep-seated. She
very positive in her statement that the tumor in the neck came on
four months before the paralytic symptoms, and that these paralytic
symptoms came on gradually, beginning in the leg, and afterward in-
volving the arm. She had had intense pain in the cervical region. Dr.
de Sehwcinitz examined the eye-grounds, and found evidenceof a slight
retinitis in each eye. There were no vasomotor or trophic disturbances.

In consultation with Dr. John B. Deaver the case was again carefully
examined and the tumor was considered to be probably a growth from
the inside of the spinal canal, extending outward, and slightly com-
pressing the cord. As the cord-compression was yet very limited in
area, only involving the left lateral tract, while threatening every day
to invade new territory with fatal results, and as the woman was already
badly disabled, it was decided that an exploratory incision should be
made. This opinion was endorsed, at a subsequent consultation, by
Dr. D. Hayes Agnew, who kindly saw the case. The operation was
accordingly performed July 17, 1888, by Dr. Deaver, in the presence of
Drs. Agnew, Ashhurst, and Mills.

The details of the operation are given by Dr. Deaver in his paper.
The laminae of the third and fourth cervical vertebra? were cut through
and the spinous processes removed, thus exposing the theca. The
swelling on the side of the spine was found to be thickened and some-
what displaced bony tissue of the vertebra. The bones were evidently
the seat of an inflammatory process, and were softer than normal.

The dura mater was thickened and opaque. There was no bulging or
swelling within it. As there was no indication for more interference,
it was decided not to open the membranes, and accordingly the operation
proceeded no further. To all appearances, the whole of the pathological
process had been confined to the bones and to the soft parts without.
Evidence was altogether lacking in the operation itself of what the exact
condition had been which caused such circumscribed pressure upon the
cord as only to impinge upon the left motor tract. The respiration of the
patient \\ n< altered during the latter part of the operation, and again before
her death three days later. This alteration consisted in deep, almost gasp-
ing inspirations with quite a prolonged interval between. Whether this
was caused by any interference with the functions of the phreuic nerve,
which is described by some as originating in the fourth cervical seg-
ment, I am not able to say. It ceased as the patient rallied from the
ether, but returned again a few hours before her death.

The patient's paralysis after the operation did not improve. Her
arm and leg were tested as carefully as her condition would admit ; she

- very weak, but evidently made an unsuccessful effort to throw the
palsied limbs into motion when requested to do so. On the third day
after the operation her condition changed for the worse, the respiration
was altered as described, she became unconscious and died. It would
be difficult to explain exactly the mechanism (so to speak) of her death.

566 LLOYD, DEAVER, TUMOR OF SPINE.

It was not expected up to a short time before her end. The surgical
conditions were aseptic and good. There was no increase of pressure
upon the cord ; at least there were no new paralytic symptoms to indi-
cate such. The wound had ample drainage. The alteration in the
respiration alone seemed to furnish an explanation.

The notes of the autopsy are as follows : The cord presented a per-
fectly normal appearance up to the region of the operation, where the
dura was slightly thickened and congested. On splitting up the dura
there was observed on the anterior aspect of the cord at about the level
of the second cervical nerves a slight prominence on the left side about
five-eighths of an an inch below the decussation of the pyramidal
tracts. This prominence was of the same color and apparent consist-
ence as the cord, was somewhat conical, and about the size of the end of
a wheat grain. The cord was not cut, but preserved for microscopic
examination. Careful examination of the external and internal cap-
sules of both the right and left hemispheres and of the motor tracts
through the crura and pons revealed a perfectly normal condition. At
the base of the brain the membranes were not involved, and the basilar
and other arteries, including the arteria hemorrhagica and middle cere-
bral, were not atheromatous. The ventricles contained a normal
amount of fluid without blood. The centrum ovale was normal, as was
the motor cortex to naked eye inspection. The kidneys showed a slight
tendency to congestion and to interstitial change.

I am indebted to Dr. E. O. Shakespeare for the following report on
the pathological appearances of the sections of the cord which he made :

Three segments of the cord were examined — the one above the lesion,
the one containing the lesion, and the next one below. The top of the
upper segment shows oil globules in the posterior columns and in the
cerebellar tracts. Below in this segment is a circumscribed lesion
involving the gray matter from the middle line forward as far as the
beginning of the anterior horn and back to one-half the length of the
posterior horn ; it also involves the crossed pyramidal tracts ; also
slightly involves the multipolar cells in the anterior horn. An upper
section from the middle segment involves the gray matter beginning
about at the posterior edge of the central canal back to the edge of
the gray commissure, and involving the posterior left horn and the
outer border of the gray matter extending into the anterior horn of
the left side ; the whole of the left lateral column is involved at this
level, including, of course, the motor tracts. The posterior root zone is
here also slightly involved. There is a small area of involvement on
the right side in the anterior column ; also slight at exit of the right
anterior nerves. The middle sections of the middle segment show
unilateral involvement of the gray matter (left tide) ami limited
involvement of the trophic cells on the right side. The anterior part
of the columns of Burdaofa is involved. The whole of the lateral
column is involved (this section corresponding to the level of the pro-
jection seen post-mortem), and on the anterior part is an intensification
of the lesion. The lower section of the middle segment involve! about the
same as the last, except that the column of Burdach is involved farther
back. The right anterior horn is slightly involved, also a limited islet
in the right column of Burdach near the column of Clark. Middle of

LLOYD, DEAVER, TUMOR OF SPINE. 567

Ki<;. I. Fie. 2. !i«;. 3.

Time-quarters inch above pro-
jection, showing ^area of as-
cending degeneration.

Above projection, allowing area
of hemorrhagic extravasa-
tion.

Still above projection, show-
ing area of hemorrhagic
extravasation.

FlO. 4.

Fig. 5.

Fio. <•.

Top of projection, showing pro-
jection and area of hemor-
rhagic extravasation.

Little below projection, showing
area of hemorrhagic extrava-
sation.

Bottom of middle .segment,
showing area of hemorrhagic
extravasation.

lower segment shows the lesions limited sharply to the gray matter of
the left side posterior to the central canal, anterior parts of the posterior
horns, and the crossed pyramidal tracts. The lesion consists, in the
main, of an extravasation of blood with a more or less complete destruc-
tion of the gray and white matter involved. There is also some inflam-
matory action principally in the neighborhood of the peripheral portions
of the hemorrhage.

Observations. — The present appears to be an era of operative inter-
ference in diseases of the cerebro-spinal system. It is well, therefore,
to publish both the unsuccessful and successful cases. From the former
is sometimes learned more than from the latter. This case, it now
appears, was beyond the aid of surgery. The lesion was too far anterior,
and too deep in the substance of the cord itself to be reached by the
knife. It was, at least, an instance of successful localization of a lesion
in the cord. The manner of the patient's death creates a suspicion that
the phrenic was in some way interfered with ; and this may serve as
a possible danger-signal to those who are about to operate upon the
cervical spine. On the other hand, it must be remembered that in our
case the bones were involved in an inflammatory process.

568 LLOYD, DEAVER, TUMOR OF SPINE.

Surgical Report by Dr. Deaver.

July 16, 1888. The day previous to the operation, the patient's bowels
were moved with a saline purgative ; the urine examined chemically and
microscopically, proving to be negative ; and the heart and lungs care-
fully examined, eliciting no organic trouble. She was given first a warm
water bath, then a boric acid bath, after which the neck was washed
with turpentine, then scrubbed with soap and water, again washed with
ether, alcohol, and enveloped with a towel wrung out of a solution of
1 : 1000 bichloride of mercury.

Operation, 17th, 1 p. M. The patient having been etherized, was placed
upon the table, and with Prof. D. Hayes Agnew and Prof. John Ashhurst,
Jr., assisting, and in the presence of Drs. J. Hendrie Lloyd and Charles
K. Mills, I made a longitudinal incision over the median line of the
nape of the neck, extending a little distance above and below and down
to the spines of the affected vertebrae; then separated the muscular
attachment and reflected the soft parts laterally on either side as far as
the junction of the transverse processes with the pedicles of the verte-
brae, thus clearing the spinous processes, as well as the laminae of the
third and fourth cervical vertebrae and their ligamentous attachments,
when was exposed a bony tumor, convex from above downward and
from side to side, being much greater upon the left side The soft parts
thus far dealt with were, macroscopically at least, normal.

The spinous processes were removed at their base with a pair of bone
pliers, then the laminae on each side were divided behind the articular
processes with the same instrument. Upon making the section of the
spinous processes, they were found to be a trifle softened, while the laminae,
particularly on the left side, the side corresponding to the most prominent
part of the tumor, were softened and enlarged, the cancellous tissue of
same containing some pus ; in other words, the condition was that of
chronic ostitis with perhaps some osteo-myelitis. Upon the removal of
the laminae, which were adherent to the dura mater, the dura mater
was seen intact at the bottom of the wound, the connective tissue nor-
mally existing here having been absorbed ; neither were there any
bloodvessels present (the posterior longitudinal spinal veins and their
connecting branches, which exist here normally, being absent). The
dura mater did not rise up into the bottom of the wound when the
bone was removed ; it presented an opaque appearance and was <piite
resisting to the sense of touch, and appeared thickened, having shared
in the inflammation of the bone. It was opened with an exploring
needle, with purely negative results, and was tougher than normal.

The operation, so far as removing any more tissue, was completed and
it remained to readjust, fix, and dress the soft parts.

A rubber drainage-tube (medium size) was placed in the wound, the
muscles and the deep fascia covering them sewed with catgut, and the
skin and superficial fascia with silver wire. The wound was dressed
autiseptically, first dinting on iodoform, covering with protective, wet
with a solution of 1:2000 of bichloride of mercury, twelve layer* of
bichloride gauze wrung out of a solution of 1 : 2000 of bichloride of
mercury, twelve layers of dry bichloride gauze, these covered with
bichloride OOttOn, ami. Lastly, with an antiseptic bandage. During the
operation the strictest antisepsis was observed, the wound being continu-
ally irrigated with a solution of 1 : 4000 of bichloride of mercury. Im-

LLOYD, DEAVER, TUMOR OF SPINE. 569

mediately after the operation the temperature and pulse were normal,
the respiration heing of the character described by Dr. Lloyd.

Patient sent back to ward ; ordered application of dry heat to body
and extremities ; ammonium carbonate, grains five every two hours ; milk
and lime-water.

i P. m., after the operation, the temperature was 97°, respiration 21,
pulse 104. 6.30 p. m., temperature 96|°, pulse 92, respiration 28.

18th. Patient passed quite a comfortable night and seemed as well as
before operation ; mind perfectly clear ; pulse 80, respiration 28, temper-
ature 99£° ; dressings examined and found to be dry and in position.
The respiration being of the same character as spoken of above, I did
not think it injudicious to order y^gth of a grain of sulphate of atropia
hypodermatically twice daily.

19th. The patient's breathing becoming more laborious, and her general
condition alarming the resident physician, I was summoned to go to the
hospital. Upon my arrival, at 12 m., the condition was as follows : pulse
100, respiration 32, temperature 99$°. The respirations being quite
shallow, electricity was applied; one pole over the side of neck corre-
sponding to the origin of the phrenic nerve ; the other, to the lower
margin of the chest, with the idea of stimulating the diaphragm. I
ordered the ammonium carbonate and the atropia to be continued, with
the addition of one-half ounce of whiskey every two hours. The dress-
ing being slightly soiled, I dressed the wound, when I found it healed
except the track containing the drainage tube ; there being no discharge
from this, I removed it and washed out the track with a solution of
1 : 2000 bichloride of mercury.

20th. No improvement ; respiration 40, pulse 150, temperature 100f°.
Thinking that her condition might be partly due to pressure from collec-
tion in the bottom of the wound, I removed the dressings, took out two
stitches, broke up the union and, examining the wound very carefully,
I found it to be clear ; I, therefore, dressed it and ordered the treatment
continued.

Patient died the following morning at 4.30.

The cause of death I attributed to inhibition of the phrenic centre,
there being no other possible explanation at which I could arrive.

My reasons for attributing the cause of death to phrenic inhibition
are that, prior to the operation, the respirations were normal, and that
during the early part of the operation nothing abnormal was noted in
the breathing, but at the latter part it was noticed to be changed and
answering to the description given by Dr. Lloyd. The only explana-
tion I can give for this is, that the spinal cord about the position of the
phrenic centre might possibly have been injured with the exploring
needle, or by some other condition not recognized. The operation, up
to the time of introducing the needle, could not in any way have in-
jured the cord, as the dura mater was in no way interfered with, with
the exception of separating it from the adherent laminae when it was left
intact at the bottom of the wound, and the needle passed through it to
determine whether or not there was any further mischief. In the future,
if I have the opportunity to operate upon the cervical portion of the

570 RANDOLPH, CONGENITAL CLOUDING OF CORNEA.

spinal cord, I certainly will not use the exploring needle as a means of
diagnosis, but, in preference, will lay open the dura mater and expose to
inspection the deeper parts; this being, to my mind, a cleaner, more
satisfactory, and, to the patient, a less dangerous procedure. In opera-
tions upon the cord in its remaining regions the use of the exploring
needle would not be so objectionable. I believe this is the first time in
this country that an operation has been undertaken with the view of
removing a spinal cord tumor, and that but two other surgeons else-
where have preceded me, namely, Mr. Macewen and Mr. Horsley. Mr.
Macewen's cases were not really tumors of the cord, but of the connec-
tive tissue between the dura mater and the spinal canal. In view of my
again meeting with a similar case, I certainly would advise operative
interference carried to the extent of exploration at least, which shall
determine the advisability of proceeding further, and I do not con-
sider that the result here obtained should discourage us at all in further-
ing the good work already done upon the cerebro-spinal axis.

CONGENITAL CLOUDING OF THE CORNEA AFFECTING
TWO SISTERS.

By Robert L. Randolph, M.D.,

AS8ISTANT 8URQEON TO THE PRESBYTERIAN ETE AND EAR CHARITY HOSPITAL, BALTIMORE, MD.

This condition is of such rare occurrence that both cases seem to be
worthy of record.

Case I. — K. M., four years old. Blue irides. A bluish haze of both
corneaj. Some nystagmus. Slight conjunctival injection. The cloud-
ing appears to involve the epithelial layers of the cornea, together with
the upper layers of the substimtia propria. Pupils react perfectly. Can
discern large objects at a short distance. Both eyes of normal size.
The child prefers shady places and avoids the bright light of the sun.
Bad teeth, but not the typical Hutchinson's teeth. Very profuse secre-
tion of saliva. Excoriation on upper lip from a long existing running
at the nose.

Head well developed, and intellect in keeping with her age. The skin
smooth and white. The limbfl straight and well formed. Has a good
appetite, rosy cheeks, and runs all about. The family physician tells
me that at birth the cornea; were almost perfectly blue, and since her
birth ho has noticed that the clouding has grown less and less, and it is
only within the past year that the irides could be seen. The epithelial
layers of the cornere have a granular appearance and lack the usual
lustre. The fundus is not to be seen.

Case II. — Jeannette M.. ten years old; sister of the Cornier. Well
developed and bright Bine irides. Her mother says that at birth her
eyes were exactly like those of her sister. Dr. Cromwell, the family

RANDOLPH, CONGENITAL CLOUDING OF CORNEA. 571

physician, has observed since be knew the family — now six years — that
the cornea) have boon gradually clearing up. There is present the same
distinct bluish haze as in the case of the younger sister, hut to a much
less degree. The corn ere have not the lustre peculiar to the healthy eye,
but still they lack the granular appearance seen in Case I. There is no
nystagmus. The child has suffered off and on during her entire life
with coryza, the excoriated upper lip giving evidence to this fact.
Teeth very unsound, but not as much affected as in Case I. Like her
sister, she dislikes bright, sunny days. It is possible to see the fundus,
but not distinctly. It appears as though seen through a cloud. She
uses her eyes for near work, and reads with considerable ease. The
clouding, as is the case with her sister, pervades the superficial layers
of the cornere, and is homogeneous throughout, except in the case of the
left eye, in which the returning transparency seems to be more marked at
the upjwr border of the cornere.

The slight photophobia present in both cases was the only annoying
subjective symptom. Whether this latter — as is usually the case in
corneal affections — is a reflex disturbance, having its origin in ciliary
irritation, I am unable to say. It could have been due to rays of light
playing upon a retina not yet accustomed to bright light, a retina which
has always been shaded by what the Germans call a darkening — Ver-
dunkelung — of the cornea. And this photophobia was less marked in
the older case, seeming to indicate that with the fading away of the
corneal cloud the retina was gradually accustoming itself to the increased
supply of light as well as to the brighter quality of the rays.

I questioned the mother clearly, but could draw out no specific history.
The father had become bald quite early in life. The mother had had
eight children. At the birth of the younger of these two sisters she had
experienced a great nervous shock, which I do not regard as signifying
anything pertinent. After Case I. the mother was delivered of one more
child, which died in convulsions six weeks after birth.

I should call the affection then a diffuse interstitial keratitis, sluggish in
character as it frequently is, indeed almost passive, beginning in the
latter part of pregnancy, and gradually disappearing with the further
growth and constitutional development of the child.

As I have said, I was unable to gather any information from the
mother which would indicate a specific origin, but the whole aspect of
the disease, its rarity, and its occurrence in sisters, seem to point to some
single and definite cause, and that was most probably an hereditary
taint.

The subject of interstitial keratitis, particularly from the point of view
of its relations to inherited syphilis, has been the theme of many discus-
sions, and notable among these latter stands out the work of Mr. Jonathan
Hutchinson. In his Clinical Memoir} Mr. Hutchinson takes the ground
that this form of keratitis is the effect of inherited syphilis.

1 Syphilitic Diseases of the Eye and Ear. A clinical memoir by Jonathan Hutchinson, F.B.C.S.
London, 1863.

572 RANDOLPH, CONGENITAL CLOUDING OF CORNEA.

He draws his conclusions from the observation of one hundred and
two cases of interstitial keratitis. The point in the diagnosis upon
which he lays most particular stress, as indicating inherited syphilis, is
the condition of the teeth. " The subjects of this form of corneal
inflammation," he says, " almost invariably have their upper central
incisor-teeth of the permanent set dwarfed and notched in a peculiar
and characteristic manner," the condition commonly known as the
" Hutchinson teeth." He has never seen a typical form of interstitial
keratitis in which the teeth were of normal size and shape.

Parinaud1 regards the miscarriages of the mother, the number of
deaths among the brothers and sisters as the important factors which
should lead us to attribute a case of interstitial keratitis to inherited
syphilis. In twenty-three out of thirty-two cases he finds these two
points well marked. He thinks that diffuse interstitial keratitis is a
manifestation of syphilis att&nuie in the parents. In conjunction with the
disease he has frequently found changes in the teeth. These changes,
however, may accompany other affections.

The majority of ophthalmic surgeons of the present day, I think,
attribute the disease to hereditary syphilis,2 though this theory has been
strongly opposed by Panas, Buffe, Mooren, and others. Panas doubts
very seriously the syphilitic origin of the keratitis. " The abnormal
configuration of the teeth," he says, " is not always constant, and when
it does exist it recalls exactly what we see in rachitis." Another point
which, he thinks, strengthens the idea that it has a common cause with
rachitis, is that mercurials avail but little in its treatment, and that
iodide of potash gives the best results. He suggests the name keratite
cachectique diffuse instead of keratite heredito-syphilitique. Neither
Hutchinson nor Panas alludes in his discussion to a congenital form
of interstitial keratitis; in short, to cases similar to the ones now reported
by myself. Hutchinson3 asserts that he has never witnessed the occur-
rence of interstitial keratitis earlier than at the age of two wars. The
youngest case reported by Panas* in his remarks was of a boy twelve
years old.

It is undoubtedly true that in a large proportion of cases the disease
is developed between the ages of eight and fifteen.

Although the cases reported by me were congenital, I do not regard
the disease in itself as differing in one whit from that form of keratitis
which has been fruitful of so inueh discussion, and to which I have just
alluded. The outhreak, however, of the inflammation in utero, and the
exceeding rarity of such an oocurrenoe would appear to justify me in
assigning these two cases, and like ones, to a separate and distinct branch

1 Arrh. g«n. de M«d., Not. 1883. » Oat. des II.'.p., 1S71, No*, 189, 140, 141

» Clinical Memoir, etc., p. 116. « Oat. dea Hop,, No. 14-2.

KANI'OLl'ir, CONGENITAL CLOUDING OF CORNEA. 573

of the subject. It behooves me, then, to touch more particularly upon
the congenital forms of interstitial keratitis.

The following description of the affection was given eighty jrean ago

by a French writer:1

" The child comes into the world with a peculiar form of blindness, due to
the darkening of the transparent cornea. This latter is of a dull bine color,
and thicker than in the normal state. This trouble appears to be produced
by a relaxation of the tissue of the transparent cornea oy the of a

lymphatic humor which is absorbed after birth, most often without medical
attention, the cornea becoming transparent at the end of a few months. In
such a case the transparency appears first on the outer edge of the cornea,
then in a circular direction around its border, and so, from place to place,
until the entire cornea has assumed its natural color."

The first cases reported were by Wardrop, in 1739, and by Klinkosh,
in 17GH. In 1790 there appeared a very interesting report of three
cases by Mr. Farar.2 The children were sisters, and they were born
with cornea? so opaque that the irides could not be seen. The opacities
gradually disappeared without treatment. In the first and second cases
the recovery was complete in ten months after birth. In the third case
the clouding had markedly diminished at the end of the first year. At
this point he lost sight of the case.

In 1841 Mr. S. Crompton,3 of Manchester, reported two cases. The
children were brothers. One of the cases seems to have been of doubt-
ful origin, purulent ophthalmia might have been the cause. There was
no doubt about the younger one. For a history of the older boy the
author says he relied very largely upon the testimony of the mother.
In the same year I find two cases reported by Mr. It. Middlemore,4 of
Birmingham. When first seen the cornese were so opaque that the
irides were not visible. The cloudings finally disappeared, leaving the
corneas wholly transparent.

In 1855 a most interesting history of this subject was given by Dr.
Fronmiiller,5 in his monograph on "Congenital Cloudings of the Cornea."
According to Fronmiiller, the highest grade of the affection is scleroph-
thalmus, which is an arrest in the development of the eye, taking place
in the first or second months of pregnancy, at the time when there is no
difference between the cornea and the sclera, when the former is thick,
flat, leucomatous. There is, at this stage, no trace of the anterior
chamber, and the iris lies immediately under the cornea. With this
malformation we necessarily have microphthalmos. The peripheral

1 Mayor: Essai sur qnelqne maladies congenitales desyeux. Une thi»e inaugurate. Montpelier,
1808.

» An Account of a Very Uncommon Blindness in the Eyes of Newly Born Children. Medical Com-
munications, vol. ii , London, 1790.

1 Medical Gazette, vol. xxvii., London, 1841.

* Medical Gazette, vol. xxviii., London, 1841.

6 Ueber die angeborenen Uornhautverdunklungeo. Vierteljahrscbrift ftlr die prak. Heilkunde,
B. xlv. S. 57-70.

574 RANDOLPH, CONGENITAL CLOUDING OF CORNEA.

cloudings generally have their existence in the third and fourth months
of pregnancy, at the time when the watery elements and the anterior
chamber form, and when the cornea begins to elevate itself and the
lamellar formation is in process of growth. The other congenital cor-
neal cloudings date from the later months of pregnancy. He divides
the whole subject into two classes : First, congenital leucomatous opacities,
in which the lamellar structure of the cornea is absent and there is an
arrest in development, the eye being always reduced in size ; the prog-
nosis is absolutely bad. Second, congenital cloudy opacities, having their
seat immediately under the external epithelium of the cornea, the latter
preserving its normal texture; the prognosis here is favorable.

The only case that I can find reported in the American medical
journals is that by Dr. Bethune,1 in 1870. The patient was twenty-five
years old. The mother had noticed at birth an opacity the size of
a pin's head, and instead of disappearing it had progressively increased
in size. This cannot, though, be regarded as a perfectly fair and typical
case, for too many important points in the history depended for their
existence simply upon the mother's recollection of what the condition
was twenty-five years before. It was quite possible that this opacity
had its origin in purulent ophthalmia.

The most complete history of the subject I find is that by Hubert.2
" It may be due," he says, " to an arrest in development, or possibly the
clearing up of the cornea goes on unusually slowly, and when delivery
comes it is not yet transparent, or it may be the cornea underwent during
intra-uterine life an inflammation the traces of which at birth had not
entirely disappeared." He refers to the fact, however, that there is only
one case on record in which the condition of the eye was due to a clearly
defined intra-uterine disease. This case, he says, occurred in the practice
of M. Panas, and is that of a woman twenty-five years old. The right
eye was perfect in every respect. The left eye was less than half the
normal size, and had all the muscular movements except abduction,
which was rather imperfect. Of course, there was no light-perception.
The patient affirmed that she was born with the eye just as small as it
was then, and, to confirm her statement, the conformation of the orbit
showed an arrest in development in proportion to the duration of the
condition. The mother had gone through with smallpox during preg-
nancy, and the patient was born with marks of the disease on her body.
There were still clearly defined scars on her breasts. Syphilis was abso-
lutely excluded. Here, then, we have the eye disease due to the variola.
The essay comprises a treatise on the embryology of the cornea, its

1 BhIM Mi '.Hi ill Mid Surgical Journal, toI. t., 1870.

* fctwlo sur U ili'Tilopincnt lie la coruoe et »ur In opacitei oongeniUlea de cert* membrane. Those,
Pari*, 187B.

RANDOLPH, CONGENITAL CLOUDING OF CORNEA. 576

norma] histology, and the pathological changes seen in congenital opaci-
ties. He inclines to Hutchinson's view as to its origin.

In 1880 M. LCclere,1 in an article on congenital opacities of the cornea,
reported seven cases in addition to the ones just quoted in this article.
He concludes that such affections are the results of intra-uterine inflam-
mation. In 1883 Couzon* reports a case occurring in the practice of
Prof. Parinaud. The infant was ten days old when first seen, and was
born with opaque cornea'. The latter were the seat of an interstitial
keratitis, characterized by a diffuse infiltration which occupied the
cornea in its whole extent. The cornea had a pale bluish tint. The
opacity hid the iris completely from view. Totally blind. No peri-
corneal injection. History of congenital syphilis. The child was put
on iod. potash, and in three months the clouding on the right cornea
had nearly disappeared, that on the left cornea had diminished in intensity.

From the preceding it will be seen that the weight of evidence seems
to be in favor of the syphilitic theory. If, then, hereditary syphilis be
the cause of that form of keratitis most often met with in children
between the ages of eight and fifteen, there would be nothing in conflict
with such an idea to suppose that this cause can and does sometimes
exert its activity at a much earlier stage in the life of the child.

There is, however, another point of view, from which many scientific
observers have regarded such cases. Hubert, in his essay, though
inclining to the Hutchinson theory, suggests the possibility of such
corneal cloudings being due to retarded development. Fronmuller also
touches upon this point. One of the strongest advocates of this theory
is Steffan.8 The latter bases his conclusions upon the anatomical exam-
ination of an eye in which the cornea was leucomatous everywhere, except
at the periphery. He thinks that all such conditions are due to a retarded
development on the part of the lens, the sac of the latter being at birth
adherent to the posterior wall of the cornea, and thus the cornea was
practically wrapped in darkness. Normally the cornea and lens have
parted at birth.

The following three cases, occurring in the practice of M. Jules Gerard,*
a veterinary surgeon, would seem to speak in favor of this theory ;
certainly the syphilitic theory can be excluded. The colts had a common
mother and father. The cornea? in each case were completely opaque,
and the affection had evidently commenced m utero. They were treated
with the ointment of the red oxide of mercury, and they cleared up com-
pletely.

1 Des opacites congunitales de la coinee. Paris, These, 1880.

* Contribution a l'etude de la keratite interstitielle dans la syphilis hereditaire *t dans la syphilis
acquise. Ibid., 1883.

* Steff.in : Be it rag znr ErklarunR angeborener Anomalien der Hornhant. Monatsblatter fUr Augen-
iirilkunde, July and August, 1867, S. 209-217.

* Keratite dn f..tus do l'espece cheyaline. Archives Medicates Beiges, xii., 1870.

576 RANDOLPH, CONGENITAL CLOUDING OF CORNEA.

Another case is reported by Riickert,1 and is that of congenital cloud-
ing of the cornea in a hog. Ruckert admits the possibility of intra-
uterine inflammations as the cause of such anomalies, but in his case
he says that inflammation could be excluded. "Against its inflam-
matory origin speaks the nature of the tissue in the opaque portion of
the cornea. It was impossible to distinguish it from scleral tissue. It
was rather a high process of organization which had taken place, for
which the peculiar vascular conditions of the area concerned might offer
a solution."

It is evident from the brief review of the literature of the subject
which I have given, that under the designation of congenital clouding
of the cornea conditions etiologically and pathologically different have
been described. It seems plain that cases in which the cornea presents
a fibrous structure like that of the sclera, in which the lens has not
separated from the cornea, in which there is microphthalmus, and in
which there is no tendency to improvement of these abnormal conditions,
should be separated from the cases in which the only pathological
change in the eye is a superficial bluish cloudiness, which has a marked
tendency to clear up after birth. The cases belonging to the first cate-
gory we need not hesitate to refer to arrest or abnormalities of develop-
ment.

Furthermore, it is urged that, as we have undoubted evidence of
arrested development in the first set of cases, cases such as I report may
be regarded simply as the slighter grades of this abnormal development.
In opposition to this view it is to be said that there are little analogy
and not sufficient evidence of transitional forms between the cases of
undoubted arrest of development, and the cases of simple diffuse
clouding of the cornea?, without other ocular changes. These latter
cases of diffuse clouding of the comeoe are indistinguishable in their
general aspect from the well-known instances of diffuse interstitial kera-
titis occurring in childhood, and it is reasonable to suppose that they
depend upon similar pathological changes. Again, it will be remembered
that physical defects, which clearly owe their existence to a want of
completeness in the developmental process of the foetus, rarely, if ever,
adjust themselves in the infant to the proper order of things. Consider
the coloboma of the iris, of the choroid, of the lids, the persisting pupillary
membrane, and hyaloid artery, all these indicate imperfect and unusual
terminations to the process of development in particular regions of the
eye. Such imperfections are permanent, they are not remedied under
the changed conditions surrounding the subject after birth. And this
is quite as true of other parts of the body as well as of the eye.

I am inclined, therefore, to refer my cases of congenital corneal cloud-

1 n 1'<,l«"»K*«rLehreTondenangeborenpnn<inilunitirUbangen. Vim. MUnchcn, 18«5.

CROOM, REMOVAL OF UTERINE APPENDAGES. 577

ing, and similar ones, to intra-uterine inflammation and not to arrest of
development.

It will be observed that in nearly every instance more than one
member of the same family is afflicted, that relationship plays an im-
pnitant rdle, relationship the result of a common father and mother.
In other words, that the offspring were exposed to some specific con-
dition or cause. Such troubles occur in all classes of a population
among the well-fed and under-fed, among the residents in the most
healthy situations as well as those of the most crowded cities. These
last facts would suggest other than a strumous origin ; they would, on
the contrary, together with the other well-established symptoms which
I have mentioned, speak in favor of the syphilitic origin of such
affections.

While this is the position which I am inclined to assume regarding
the pathology and etiology of this affection, it must be admitted that
considerable caution should be exercised before reaching any positive
conclusion on these disputed points. The fact that an apparently
similar affection has been observed in the domestic animals is not easily
reconcilable with the theory of its syphilitic origin. Undoubtedly, a
conservative view would admit different causes as capable of producing
this disease. I am, however, so much impressed with the resemblance
between the congenital and the post-natal forms of diffuse interstitial
keratitis and the syphilitic origin seems so well established for the latter,
and has been demonstrated for a certain number of cases of the former,
that for the present, at least, I prefer to regard the congenital and the
post-natal forms as etiologically as well as pathologically the same.

REMOVAL OF TtfE UTERINE APPENDAG1>.

A REPORT OF THE MORE REMOTE RESULTS.

By J. Halliday Croom, M.D., F.R.C.P.Ed., F.R.S.E.,

PHTRTCTAN TO AND CLINICAL LECTURER ON DISEASES Or WOMEN AT THE ROTAL INFIRMARY ; PHYSICIAN

TO THE ROTAL MATERNITY HOSPITAL | AND LECTURER ON MIDWIFERY AND DISEASES OF WOMEN

IN THE SCHOOL Or MEDICINE, EDINBURGH.

The present communication aims to present the results, after the lapse
of not less than a year, of the removal of the uterine appendages for
various morbid conditions, and to discuss the immediate results, risks,
and technique of the operation generally.

The operation has been performed 34 times, as shown in the sub-
joined list :

578 CROOM, REMOVAL OF UTERINE APPENDAGES.

Bleeding fibroid G times.

Bleeding uterus 2

Simple dysmenorrhea 3

Haematosalpinx 4

Double hydrosalpinx 1 time.

Simple or gonorrheal salpingo-oophoritis . . .18 times.

In the cases of the fibroid tumors the results have been, except in one
case, entirely satisfactory, both with regard to the cessation of the hemor-
rhage and the diminution of the tumor.

In three cases the women were married, under thirty years of age,
and sterile. The tumors were small, soft, and very hemorrhagic. In
none of these cases was the uterus larger than a three months' preg-
nancy. The patients had undergone all the usual treatment without
any beneficial result. The net result now, at the end of not less than
a year, has been the entire cessation of hemorrhage, beyond an occa-
sional menstruation in all of the three, and the almost entire disappear-
ance of the tumor in one. In the other two the uterus is much less ; in
both cases lying well down in the pelvis.

In the fourth case the fibroid tumor reached two fingers' breadth
above the umbilicus. The hemorrhage had been continuous for months,
and the woman unable to work. In addition to the hemorrhage, she
complained of great pain in the left side. In this case I was obliged to
use the clamp and cautery, as, owing to the splitting and shortening of
the broad ligament, the Staffordshire knot was unavailable. The opera-
tion was performed one and a half years ago, and the result is, the tumor
is half way between the umbilicus and pubes, and the hemorrhage has
entirely ceased. In respect of the pain in the left side, this was, no
doubt, due to a cyst about the size of a hen's egg in the left ovary.
The pain, also, has disappeared. This symptom of pain, associated with
fibroids, seems to me often due to this cause. Although it cannot be
classed with the present series, yet I may refer to a case upon which I
operated recently, simply for the relief of pain associated with a fibroid
tumor — the tumor being neither hemorrhagic nor increasing in size.
The left ovary presented a cyst the size of a goose egg. Its removal
was accompanied by entire relief of the pain. The former case seems
to me a particularly satisfactory one, as such complete cessation of
hemorrhage is not usually obtained in the large tumors. It is, I believe,
generally recognized that the best results are obtained where the ateroi
is not larger than a four months' pregnancy. In the fifth case there
has, at the end of fourteen months, been neither a cessation of the
hemorrhage nor any diminution of the tumor, nor relief from the
general discomfort which it caused. As the tumor was intrapelvic —
apparently interstitial — and the uterine cavity not much enlarged ; as
the ovaries were entirely removed, and as much of the tubes as was

REMOVAL OF UTERINE APPENDAGES. 579

possible, quite as much as in the other cases — it seemed jn>t the case
in which one might reasonably expect a complete cure, and I cannot
venture to suggest an explanation for ray complete failure.

The sixth case hat scarcely completed the required year. She was a
multipara, of thirty six years, with a fibroid about the size of a five
months' pregnancy. Her hemorrhage had been so profuse that she had
to be brought to the hospital in an ambulance wagon. After a few
weeks' rest the ovaries and tubes were removed in the ordinary way.
Two months afterward the patient had a rather severe hemorrhage.
Since then — seven months — she has been quite free. The size of the
tumor remains unaltered.

About a year ago, September, 1887, 1 began the treatment introduced
'by Apostoli, and have avoided the removal of the appendages for fibroid
tumor, hoping that the electric treatment would supersede the abdominal
. >n. In all my private cases the electric current has been adminis-
tered and directly superintended by Dr. Milne Murray, and in the hos-
pital by Dr. Haig Ferguson, under Dr. Murray's direction. I mention
this because Dr. Murray's name is so well known with regard to electric
work as to be a guarantee that the administration was carefully and
utifically conducted, and I am obliged to say most reluctantly that
the results have not, by any means, realized my anticipation. In none
of the cases have the results, so far, been permanent. In all there was
distinct improvement as regards hemorrhage and general comfort while
tic lasted, and in some few cases there was a temporary dimi-

nution in the size of the tumor.

This is not the place for me to discuss this method and its results in
detail. 1 only wish here to say that, so far as my experience of it goes,
it does not compete with the abdominal operation — that is, in those
fibroid tumors which seriously compromise the health and life of the
patient — and these are the only cases in which, in my opinion, the removal
of the appendages is justified. It may be premature to offer an opinion,
but, from my year's experience of Apostoli's method, I should be inclined
to place electricity so applied among the haemostatics and palliatives,
not among the methods of cure — occupying a position similar to many
well-known drags. Certainly I have seen graver risks to life with this
method than I have ever met with in removing the ovaries for bleeding
fibroids.

With regard to the case of bleeding uterus ; by this term I mean that
the uterus was perfectly normal in size and that nothing could be felt
abnormal in the pelvis beyond slightly enlarged and tender ovaries.
The patient was a single girl of twenty-four years of age. She had
been under my care for four years for persistent and continuous uterine
hemorrhage. With the exception of the Apostoli method, with which
I was not then acquainted, I believe we exhausted every means for

TOL. 96, ML >'».— DECEMBER, 1848. 38

580 CROOM, REMOVAL OF UTERINE APPENDAGES.

checking hemorrhage. In spite of all, she bled on and was completely
unable to perform any duties. As a last resource, I removed her ovaries
nearly two years ago. There has been no return of hemorrhage nor
even of menstruation, and the girl is now in robust health and per-
forming the arduous duties of teacher in a Board school.

The second case of bleeding uterus was almost identical — a single
woman of twenty-five, in whom nothing was found abnormal on local ex-
amination, but who had suffered from constant hemorrhage for over two
years. The operation was performed in July, 1886, more than two years
ago. She had irregular hemorrhages for the first year. During the past
war they have ceased. She is now well and able for her work. She is
now employed as a domestic servant.

Three times I have removed the appendages for simple dysmenorrhea
in young unmarried women. I know such an operation is coming very
near to dangerous ground. I know how open such interference is to
abuse, and how carefully operations under such circumstances must be
weighed and explained. In these three cases I could find nothing morbid
in the uterus or ovaries before operation, and the changes in the ovaries
after removal were trifling. The patients were comparatively well
between the periods, but during the menstrual week the suffering was so
great that they were unable to retaiu their situations. They had all
been under treatment for years, and it was not without misgiving and
entirely as a last resort to enable the girls to gain their livelihood th:it
the operation was performed. In each case the desired result has been
obtained. In two cases menstruation has been entirely in abeyance
ever since — eighteen months ago — and in the third, though the girl
menstruates irregularly, she does so without pain.

Four times the operation has been performed for hamaUhvtfpinx.
Two have been complete failures in respect of ultimate result. One was
a left-sided hsemato-salpinx about the size of a foetal head. The tumor,
which consisted of the enormously dilated proximal end of the hit
Fallopian tube with the distal end thickened and the fimbriae spread
out over it, was very adherent and burst in my attempt to remove it.

When I first felt it, it was about the size of a foetal head ; but on ex-
traction, after rupture, it was no bigger than a good-sized orange. I
was under the impression at the time that it was a tubal pregnancy, and
that the ovum had escaped Into the abdominal cavity. This was. how*

ever, ■ mistake, as ao trace of ■ decidua or anything to indicate pi
nancy could he found. It was an unusually large, possibly unique,
hematosalpinx. The appendages were removed July, 1886. There-
port, October, 1888, is that, so far as hemorrhage is concerned, she still
has flooding, has constant pelvic pain, and is in general bad health.
Locally, no morbid condition can be discovered. The net result is
failure.

CROOM, REMOVAL OF UTERINE APPENDAGES. 581

The second ease was a married woman, aged twenty-five, with con-
stant pelvic pain and hemorrhage. The local condition was: The
uterus retro verted; right ovary lying low down, corresponding tube
vi tv tender and dilated ; left tube as large as a Cambridge sausage and
coiled round uterus to the back; left ovary not distinctly made out.
For two months after admission to hospital I pereeveringly tried hot
water, rest, ergot, etc., but she continued to bleed in spite of all.
Therefore, after duly explaining the operation to her, I operated, and
found the left tube much larger than my examination gave me to be-
lieve— as big as a good-sized orange, and filled with clots. It ruptured
during removal. The left tube was as thick as the little finger. As the
ovaries could be of no service without the tubes, I removed them also.
Operation, July, 1886. In autumn, 1888, patient still has hemorrhages
and pelvic pain. Local examination reveals no morbid condition.
Result, a failure.

In the third case the cure has been complete. It was a left-sided
hematosalpinx. Both ovaries were removed. There has been no hemor-
rhage since.

The fourth case has so far been a success, but she has not yet com-
pleted her year of probation. It seems to me remarkable that the first
two should continue to bleed and the two latter cease. The operations
were identical, so far as the removal of the organs is concerned ; in each
I merely state the facts, and offer no explanation. The hydrosalpinx
case is well and free from any symptom.

With regard to the last class, viz., cases of salpmgo-odphoritis, either
of puerperal or gonorrhoeal origin, which form the largest group, in-
cluding 18 cases, the classic symptoms were all present, viz. :

a. Premenstrual dysmenorrhcea.

6. Constant pelvic pain.

c. Sterility.

d. Usually menorrhagia.

e. Inability for work.
/, Dyepareunia.

g. General bad health.

In every case those symptoms have been present for lengthened
periods varying from six to fifteen years, and in all of them other treat-
ment had been continuously tried without avail. Out of the 18, I can
give no record in 4. In 2 cases ventral hernia occurred. These hernia?
exist to such an extent as to detract very much from any benefit the
patients have received from the operation. In one of these cases the
hernia is complicated with a pelvi-abdominal fistula, through which
the patient has a monthly discharge in addition to the ordinary vaginal
one. This patient menstruates regularly, as, owing to extensive adhesions,
one of the ovaries had to be left. The following is a report of the case :

682 CROOM, REMOVAL OF UTERINE APPENDAGES.

She had been married for twelve years, and contracted gonorrhoea
shortly after her marriage ; ever since she had been a constant sufferer ;
sterility with dysmenorrhea, and inability to perform her marital func-
tion. Per vaginam the uterus, ovaries, and tubes were matted in one
solid mass. Bimanually, under chloroform, the uterus could be felt
lying forward, fixed firmly on either side by two solid lumps occupying
each broad ligament. I removed the ovary and tube on the left side
with great difficulty, they were so firmly adherent. The ovary was
enlarged and cystic, and the tube much thickened and containing pus.
I removed the right tube after much trouble, and found it acutely
inflamed and thickened. The corresponding ovary I could not remove ;
it was small and firmly adherent ; I, therefore, left it. The operation
was a difficult one, the roof of the pelvis being completely closed in by
adhesions.

There are three points about this case to which I specially wish to
draw attention. First. The abdominal wound did not completely heal,
leaving a small sinus at the lower angle. Through this sinus there lias
been a hemorrhagic discharge at each menstrual period. The wound is
perfectly free from any sanguineous discharge from its edges. The
hemorrhage is not, therefore, in any sense vicarious, but wells up from
the pelvis through a sinus three inches in length. This discharge
has been regular every menstrual period, and simultaneously with and
in addition to the ordinary menstrual discharge per vaginam. Second.
Menstruation has continued with regularity ever since, but without any
pain or distress, and that although one ovary still remains on the pelvis.
Third. The patient got immediate and continuous relief, and had abun-
dantly expressed before my class her opinion that her relief was well
worth the risk.

Such was my report of the case in December, 1886. Now, after the
lapse of two years, 1 am obliged to place the case among the compara-
tive failures, as the discomfort of the hernia and fistula combined i-
sufficient to counterbalance the other benefit of the operation.

Of the remaining L2 : in 5, at the end of a year, the cure has been
complete — i. e., the patients now enjoy good health and are able to pursue
their ordinary avocations. Of these 5 cases, I possess written records
from themselves. 1 has been a complete failure, owing to some para-
metric inflammation succeeding the operation. The patient menstruate!
occasionally, and is never free from pelvic pain. 6 present only partial
cure, as follows :

5 still have pelvic pain, in 1 owing to one ovary being irremov-
able, in the other 8 to parametric inflammation. The fifth case mi
that of a nervous hysterical woman. Her pelvic condition was not, as
I then believed, the main factor in her distress. The removal of the
appendages has given only partial relief. In a similar ease I should

OHMANN-DUMBSNIL, LIPU8 OF H.\ 583

n<»t 0] It is noteworthy that in this case the removal of her

i. \ai'u> lias increased her sexual appetite in quite a marked degree.

In the sixth case there is persistent dyspareunia, the cause of which
is iic >t apparent on local examination.

In this group of 18, in 6 menstruation has been entirely in abeyance
since the operation; 10 menstruate at irregular intervals; 2, in whom
one ovary was left, menstruate perfectly regularly.

In all the 34 cases, with the two exceptions I have just referred to,
the appendages on both sides were completely removed.

ERYTHEMATOUS LUPUS OF THE HAND.
By A. H. OHMA.NN-DrMK-.vn.. A.M.. M.I).,

OF 8T. LOUIS.

Lupus erythematosus (Cazenave) is an affection of the skin which has
proved itself interesting, not only from a clinical point of view, but
because there has been so much discussion in regard to its pathogeny
and pathology. Its clinical characteristics and appearances have been
minutely described and made thoroughly familiar; yet they have not
been so carefully elaborated as we might wish. What I intend to con-
is this : that while erythematous lupus of the face and head has
been quite frequently observed and described in every particular, and
every phase of its evolution noted, the invasion of other portions of the
skin has either escaped attention or has occurred so seldom that but few
cases have been observed and of these but a small number have been
accurately described.

That this disease occurs most frequently upon the face is fully proven
by the statistics of every dermatologist ; and that its occurrence upon
the trunk or extremities is comparatively unusual is also the general
experience of those who have paid any attention to the subject. It is
the universal opinion of all authors that erythematous lupus of the
hand is a rare form of the disease, and the rarity is still greater when
the process is not found to be present upon any other portion of the body.
This being the case, it is very strange that the reports of such cases
which have been made, should, in a certain degree, be so meagre in
details and I must urge this very incompleteness as an apology for the
apparently unsatisfactory manner in which I have been compelled to
tabulate the cases which I have succeeded in gathering together.

There is no doubt whatever, in my mind, that these do not represent
more than a very small portion of the cases which have occurred, for

584 OHMANN-DUMESNIL, LUPUS OF HAND.

two reasons. In the first place, many observers are unable to recognize
the disease; and, in the next place, others observed it before it had
acquired a distinct place in nosology. Yet, it must be comparatively
infrequent when we take into consideration the number of competent
dermatologists and the large amount of material which passes through
their hands, in connection with the small number of cases of erythema-
tous lupus seen by them and the extremely small number of patients
whose hands are affected by this disease. Of course, in the majority of
cases, there is not much pain or deformity and scarcely any inconven-
ience attending the disease, relief being frequently sought for cosmetic
purposes. This may act as a possible factor to account for the small
number of cases actually observed.

On account of these and other reasons, I have deemed it proper to
report a case of erythematous lupus of the hand and arm, which came
under my care some time ago, and which possesses some interesting
features. This is done in spite of the fact that the case is still under
treatment and observation.

Case. — W. C. C, male, aged fifty-five, was referred to me ou June 3,
1886, by Dr. F. Foster, of Memphis, Mo. The history of the case
which was giveu to me, was as follows: The patient, whose occupation
is that of a carpenter, is an American and married. His children are
all healthy. His own general health has always been good and he has
never had any other skin disease. There is no history of syphilis, nor
is there any evidence of its ever having existed. The patient has always
lived a regular life and his habits have always been temperate.

In June, 1882, he noticed a small "spot" upon the dorsum of the
right hand. This remained and slowly increased in size until, in the
course of a month, it had attained the dimensions of a silver dime, the
color being that of a ripe cherry. The patient cut into this with his
pen-knife and, from this time on, it began spreading rapidly. He was
treated by a number of physicians who applied caustics, using chiefly
chloride of zinc, but with negative results. In fact, he thought that the
treatment greatly aggravated the trouble. In March, 1883, he went
to Hot Springs, Ark., where he again submitted to a treatment with
caustics, but without any benefit.

On July 6, 1883, he was seen by Dr. Foster. The lesion then em-
braced the entire dorsum of the hand and extended up to the second
phalanges of the tinkers. Dr. Foster removed a portion with the knife
and was niueli gratified to see the wound heal kindly. After that time,
In- removed several large portions, the operations being always followed
by " healthy granulations." The patient could never be persuaded to

e chloroform ami have all the diseased portions removed by exci-
sion; hut, he continued to ply his vocation until his physical condition
compelled him to abandon it.

June 3, 1886. 8tatm prcesens: The patient is about 6 feet 81 inches
in height, weighs about 160 pounds, and appears physically well devel-
oped. His pilous system is well developed and his skin IS of normal
thickness and elasticity. The color is normal on the covered portions,
thi' face and hands being bronzed through exposure to the sun. The

OHM ANN-DUMESN'IL, I.FPU8 OF HANI'. 585

hair of the head is of a brown color, slightly mixed with gray. Upon
no portion of the body, exoepl the parts about to ibed, can any

affection of the skin be found. The part involved includes the bandana
arm of the right Bide. Here it may be noted that, in general, it is
the dorsum of the hand and the extensor surface of the forearm that are
implicated. The patches are rather irregularly distributed on account
of the cicatrization which has taken place. Upon careful examination,
patches are found distributed about BS follow.-: One on the dorsal

if the thumb, involving the metacarpal and firsjt phalang
surfaces, and a smaller one, the second phalangeal surface, up to the
nail but not implicating it. A very small patch is found upon the
first phalanx of the index finger, another on the first phalanx of the
middle finger, one on the first phalanx of the ring finger, and one
involving the first and second phalanges of the little finger. An irregu-
larly clover-leaf-shaped patch involves the skin over the metacarpo-
phalangeal joints of the middle and ring fingers and extend-; up on the
dorsum of the hand. Two or three patches are located over the carpo-
metacarpal joint, on its dorsal aspect, one of the patches the largi
encroaching upon the ulnar aspect of the wrist. A number of small
patches are irregularly distributed over the dorsum of the hand About
two and one-half inches above the wrist-joint a heart-shaped patch exi
and this is surrounded by cicatricial tissue. At the junction of the mid-
dle and the upper third of the forearm we find an irregular horseshoe-
shaped patch, which is so large that it encroaches upon both the ulnar
and radial aspects of the arm. Its convexity is directed upward and,
in the space included within its curve, a few small patches are present.

The sizes of the patches vary quite considerably. Some of them are
about a fourth of an inch in diameter, and all dimensions can be found
between this and four inches by one, which is approximately the dimen-
sions of the largest one. The shapes of the patches are also irregular,
although all of them have a tendency to assume convex contours.

The patches have a somewhat dark-red color, inclining to a lighter
shade. On the fully developed lesions may be observed dirty, yellowish
crusts a line or more in thickness, and consisting, in large part, of in-
: sebum. At some points these crusts are brownish from the
admixture of blood, and everywhere are hard and stiff. They are well
defined against the skin and feel quite rough to the touch. In addition,
tiny are elevated above the general surface of the skin, and when re-
1 it is noticed that an elevated border surrounds the lesion.

lift ween and surrounding some of the patches are superficial cicatrices.
These are especially pronounced between the highest patch and the
wrist-joint. Some are to be seen upon the fingers, and they have the
■ characteristics as the others. These scars are nearly white in color,
having a slight pinkish tinge. They are quite flexible and, to the touch,
communicate the sensation of a thinner skin rather than that of scar
ie. Upon close inspection, it is noted that small pits or depressions
can be found irregularly distributed in some of the scars, giving that
cribriform appearance seen to accompany cicatrices which are due to
superficial destructive processes of the skin. External inspection does
not reveal the presence of hairs, coil or sebaceoum glands.

As regards subjective symptoms in this ease, the patient states that he
has had no occasion to complain, beyond experiencing a sharp pain at
varying intervals. Sensation appears to be very fair in the forearm.

586 OHMANN-DUMESNIL, LUPUS OF HAND.

and there is apparently no disturbance of innervation. The patient
protects the arm and hand by means of a wet bandage laid over the site
of the disease, and this may account, in part, for the immunity from
l>:iin. He complains of pain upon flexing the fingers, and says that there
is a diminution in the power of the hand. He is not as strong in the
right hand and arm as he formerly was.

With this history, the diagnosis of erythematous lupus was made.
The treatment ordered was as follows : To apply a paste, composed of
concentrated lactic acid, to which sufficient kaolin to form a firm paste
had been added, to the patches, the edges of which had been previously
oiled. Dr. Foster carried out the treatment.

June 18. The paste was applied and proved to be exquisitely pain-
ful, so much so, indeed, that it became necessary to keep the patient
under the influence of chloroform for nearly three hours, and it was only
twelve hours later that he felt comfortable.

22d. A slough separated and the case is looking well.

August 11. The case is progressing finely. Applications of sapo
viridis, to be followed by zinc oxide ointment, were ordered.

20th. Case nearly well. Pyrogallic acid ointment ordered.

January 16, 1887. The patient wrote that the " sores " looked smooth
and healthy.

February 8. The "sores" show no disposition to heal.

19th. The condition seems to remain in ttatu quo.

March 10. The condition is about the same, with the exception of a
new patch which has shown itself above the elbow.

June 5. The hand has become worse and the patch on the arm is
now four inches in diameter. I urged the patient to come to the city, as
I could do nothing by correspondence.

September 24. The patient presented himself, and his condition was
nearly as bad as when I first saw him. I excised a small lesion on t In-
arm and the wound healed kindly by the first intention. He was ordered
to remove the crusts every day by means of a warm bichloride of mer-
cury solution, and then apply a mixture of equal parts of olive oil and
campho-phenique to the lesions. Under this treatment he steadily im-
proved for two weeks and left for home.

October 15. The condition again at a .standstill ; an ichthyol oint-
ment ordered.

December 8. Patient reported no improvement. I urged him again
to come to the city.

February 24, 1888. Patient presented himself once more, and his con-
dition was anything but good. He was ordered "cold cream" to the
patches, which were quite painful.

March 4- The compound salicylic plaster, as recommended by Dr.
Klotz, of New York, was applied. This proved very good in its action,
but so painful that the patient positively refused to continue its use.

14th. Creasote was applied to the elevated edges of the patches and
campho-phenique to the central portions. This treatment gave good
results. The patient left a lew days after, but continued the treatment

at home, and one month later (April 15th) his physician reported him
■■ doing very WelL Since thai time I have received no news of the
progress of the case, which has, on the whole, been about as unsatisfac-
tory as the majority of cases of lupus erythematosus are when subjected

to treatment

OH M ANN- I»U MKSXIL. LUPUS OF HASH. 587

It m ■ well-known foci that cases of erythematous lupus are, asa rule,
essentially chronic ami very rebellious to treatment. While single
lesions may be caused to disappear, fresh outbreaks are constantly recur-
ring. It is also a matter of observation that, in the majority of cases,
the patients disappear before complete results are attained. Moreover, as
relapses are so prone to occur, it is a very difficult matter to form any
just estimates of the results of treatment. On this account I have re-
frained from particularizing or dilating on this point, deeming a clinical
analysis of cases of more interest.

Neither do I intend to touch upon either the pathogeny or pathology
of the disease at present, reserving these two interesting subjects for some
future paper, in which I intend to present some of the results of a few
researches made in this direction.

CUBICAL An\i.y>i-. — A search through literature, and correspond-
ence held with dermatologists in this country, have resulted in the record
of forty -six cases, exclusive of the one just described. Of these, ten are
unpublished. Upon looking over this list, I find that the majority have
one fault in common, viz., the incompleteness of the record. This is due
to a number of causes. One is that some observers directed their atten-
tion to but a few points ; others did not keep notes of the cases at the
time they were seen ; and others kept incomplete records or made insuf-
ficient reports. I have been informed by some correspondents that they
could not supply me with any information on the subject, because they
did not keep notes of any cases.

In looking over the table, we find that of the 26 cases wherein sex
is specified, 15 were females and 11 males, thus confirming the statistics
of erythematous lupus of other portions of the body. Where the sex
is not specified > in 21 cases) it is very probable that the disease occurred
most often in females. The proportion is approximately two to one, in
the experience of all observers. In the above cases, involving the hand,
it is nearly one and a half to one, but the record is not sufficient ly
complete to arrive at a satisfactory conclusion.

The earliest period of life at which the disease occurred is given as
7 years ; the latest, as 50. The average age is 26.6. Here we must
take into consideration 28 cases in which these details are not reported.
The age at which the reporter saw the patient is more fully given, there
being but 22 cases in which this item is omitted. In the remaining 25
cases, the youngest was seen at the age of 12 ; the oldest at 60. The
average age when seen is 33.7. Taking the 19 cases in which both the
age at which the disease first made its appearance and the age at which
the reporter saw it, are given, we find that the shortest time permitted
to elapse between the appearance of the disease and its presentation to
a competent observer is 2 years ; the longest, 21. The average time is
years. Of course, many of these had been seen and been treated

588

OHMANN-DUMESNIL, LUPUS OF HAND.

«3

5 "8

< -

£•0

Face

... Fingers

— 3

Both

- i

o ° u 5

Fingers Dorsum

Nose
and
cheek

Ears

and
cheek

Lids

and

neck
Cheek,
ears and

scalp

Ears

and

*r a

Observer, and
when

published.

Face Face Both

PilllllS

and
doraom

...

Kxtrem-

itil'S

M
86

Fingers

V ...
Face

Left

...

Mi.Ulo
iiml
little

Dutwi

•21

■■

Both

ThIiiim

E. Cazenave :
Annates dM n 1:1 1 .
de la peso et At
la syph., i. '297,

1850-51.
E Wilson :
\ Journ of Cuta
neous Medicine,
Jan 1868.

I \ minimi :
Beltrag / Kent-
ill.-, der Lnp.

Kiyth. Wiin.r
mod. Wmli., No.
68, It

M. Kohn:
Arch, fiir Dorm,

II Syi-I

M l\;iposi :
Arch, fiir Derm.
ii Svph , 1'rag.
1878.

Tilbury Fox :

UImoI >Uin Dis-
! eases. I'hila.
WW, P 74.
I. II BtOWTl :

I'niiiM. Hi it Mc.l.

Assoc. Ar.li.

Delimit. I . p. 41;;

.1. Miltoa :

\1.I1 Delimit ,

ii p. i:ll.
A. Jam

Minim

Joara- p. 1008,
1878.

I. I». llulkley :

.l.Mirn. Cut. ami

Yen. Dis., ii. 3,

1879.

BhfJM.

Due linger
ainp ut. ittnt.

Diminished

powi 1 of

tl.\i..n.

OH M A NN-DU MKSM L, LUPUS OF E ATX 13

= .

* V

* t

< ;

c g

2?«8

Face
KM

1 \e e

Both King

41 I

31 ...

U 14

38 F.

nut***.

Both

Hand

Lip and

ili in

-urn Cured un-
der tn-ut-
111. iu

Bight
Left

Fingers i'ttlm

Bight

Slightly
improved

miller
treatment

SO 50 M. Bight
middle
finger

37 IS 4" f. Hand Fore-
arm

38 26 3«i f. Hauds

Both

Middle Dorsum

; of hand i

finger

and

lateral

iif finger
! Dorsum
of hand;
: dorsum

and
: lateral ;

■■MCI
! offings

Negative

J. Uutchinaou : 1
Lectures on Clin, "pulple*
irt 11.

J. N. Ily.l- : Thumb nail

Journ Cut. and nut attacked.
v,-i, D
1884, p. 321. '

Bight-
handed.

Melutl'xler-

inic striss
of face.

Used right ♦
hand con-

: tljr.
Bhagadea.
II i. Kioto:

Jouru. Cut. and sumption ;
Cenito-l'riiiary nail Dot
: Diseases, Feb. at!'
1888.

Index
and

middle
of left

hand

Negative; 0. Rosenthal :
tried all Deutsche iu-.I.
W'lk hschr. No.
l!i, 1887.

39 31

e Face Bight

R -
thumb,

ill'b-X,

and lin-
ger.
L-all
bat lit-
tle fing.

Paijuelin's

cautery
(punctate)
arrested it

Cured
when pre-

R. \V Taylor.
Unpublished.

40 48 60 M. Bight

thumb

Both

Left

index

Nose

Left

band

Maud

'•

:.:,

Bight
hand

Bight

arm anil
forearm

Both

Dorsum
thumb and
and radial
index ; aspect
L of right

thumli thumb
Dor-urn Dorsum;
of index' few
spots on

palm

Thumb Dorsum
and
little '

Cured ; "

much re-
lieved iu
six tin*.

Cured in C. Heitzman.
eight nios. Unpublished.

Nearly 9 H. Fox.
well in one Unpublished.

month ;
relapse in
on- jm*.

Cured S. Sherwell.

Unpublished.

James C.White V. oth-r
Unpublished. |»>rt ;

the hands

afli

Right AH Dorsum Nearly A. H. Ohmann- Diminished
cured : Dum— nil.

rela| - <■ on.

improved

590 OH MANN-DUMESNIL, LUPUS OF HAND.

by physicians, and one of the cases was cured when seen by the
observer who reports it (see table, No. 36). The length of time allowed
to elapse, however, is always somewhat considerable and is in some
measure an indication of the comparatively small amount of annoyance
caused by the disease in its earlier stages.

The part first implicated is a matter of some interest. This fact is
reported in 41 cases. In these, the fingers were the portion first affected
in 15 cases ; the face in 12 ; the hand in 13; and the forearm in 1. In
this last case the arm was continually exposed, but this seems to have
played no part in the production of the disease.

Besides the hands or fingers, we find that in a number of cases other
portions of the skin were involved. In the 29 cases in which this is
noted, the nose and face are mentioned most often. It is only in Nos.
36, 37, and 47, that some portion of the face or head was not also in-
volved in addition. In 12 of these cases the disease began in the face, so
that in 16 cases the parts other than the hands were invaded subsequently
to the appearance of the disease upon the latter.

In the entire list of 47 cases, specific information as to the hand im-
plicated is given in 33. Of these, both hands suffered in 16 cases ; the
right only in 5 ; the left only in 4 ; "one hand " is mentioned four times ;
and 4 are unspecified. Or, adding together those specified, we find that
in 16 both hands were involved ; and in 12 one hand only, or very
nearly in equal proportions. 6 males and 10 females had both hands
affected ; 4 males and 1 female, the right hand only ; and 1 male and 3
females, the left hand only. The affection was as severe on the left
hand of a right-handed individual as on the right of a right-handed
one. The amount of use to which a hand is put seems to exercise little
or do influence upon the severity of the involvement.

The seat of the erythematous lupus of the hand is also a matter of
some' interest. The dorsal aspect of the hand is apparently the site of
predilection. In 25 cases in which the location is mentioned, the dorsum
was the seat of the disease in 17 cases ; in 3 the palm alone was affected ;
and in 2 both dorsum and palm were implicated. In 3 cases the side of
the hand was affected, and in 1 the ends of the fingers.

In li rases there were fissures observed in the hands, and in 1
(No. 28) the pulps of the fingers were atrophied, this being probably
due to the fact that the ends of the fingers were affected by the disc
In several the power of flexing the hand was markedly diminished.

In regard to the general condition of the patients, it may be stated
that, while a number of authors report a depressed general state, others
report their patients as being apparently in good health. As this
matter is not fully dwelt upon by authors or by those who have reported
Cases, it i- imi pottible to be OOnelniive on this point. In my case, the

SHEPHERD, MANIA FOLLOWING OPERATIONS. 591

patient has always been in a good condition physically, and has never
complained of any other affection than that on his hand and arm.

I wish to acknowledge valuable assistance from several papers on the
subject of this essay, notably Dr. J. X. Hyde's {.Journal <,/ Cutaneous

I Venereal Diseases, 1884), and I also seize this opportunity to extend
my heartfelt thanks to all the gentlemen who so kindly and ooorteonalf
answered my letters of inquiry.

In conclusion, I think that the foregoing analysis justifies me in draw-
he following conclusions:

1. Erythematous lupus of the hand is a form of the disease which i>
comparatively of infrequent occurrence.

2. Like the disease in other localities, it is found more frequently in
women than in men.

3. This forms begins most frequently on the hands or fingers.

4. In the majority of cases the face or the head is also implicated.

5. Both hands are not more frequently involved than one hand alone.

6. The disease generally makes its appearance when adult life is
ied.

7. 1 1 is essentially chronic in nature and rebellious to treatment.

v. The therapeutic results obtained are, in general, not satisfactory.
'•'. The disease does not seem to impair the general health.

MAMA FOLLOWING OPERATIONS, ILLUSTRATED
BY SIX CASES.1

By Francis J. Shepherd, M.l>.

Fftoraaom or akatomt ix MBU vmiversitt, bteqzon to the monteeal or. meal hospital

The fact that insanity may follow accidental or surgical injury, other
than that involving the brain and its membranes, has long been recog-
nized, and not a few cases are reported in medical literature. I ndividuals
addicted to alcoholic excesses not infrequently, after severe injuries,
illy of the lower extremities develop delirium tremens, and, indeed,
it is not so very uncommon to see delirium follow severe injuries of the
lower extremities in persons who are not habitual drinkers. < >nly a
short time ago I saw two cases of delirium following intracapsular
fracture of the femur in old women. The cases, however, which I
to notice, are those in which insanity is developed after surgical injury.

1 Read before the Surgical Section of the Canadian Medical Association, Ottawa, 1888.

• As for example, A. Schroetter : I>e Morbis Animi praecipue in rombinatlooe Tulnerum, l&M Also
Bmmt, 1851 ; Heyfelder, 1872. J. Festal : Du Delire nerveux traumatique. Davidson : Mania after
Amputations Lancet, 187.5. G. Spies : Zur Casiustik der traunutuchen Manie, 1860.

592 SHEPHERD, MANIA FOLLOWING OPERATIONS.

In these cases, when anaesthetics are administered and iodoform used, it
is often difficult to decide correctly the cause of the mania.

In persons predisposed by heredity to insanity, any shock or disturb-
ance of function may produce an attack of mania, and any disease in
which delirium occurs may set up a chronic mental disorder. We see
this in the delirium produced by fevers such as typhoid, also pneumonia.
Dr. Savage' says that " those who come of insane stock are very often
unusually liable to infection, and having contracted an acute disease,
they are more likely to have early and severe delirium."

Cases of insanity, melancholy, etc., are reported from time to time
following operations on the female genital tract. Not a few cases of
insanity following ovariotomy8 are recorded, and in a recent paper by
Werth six cases of psychical disturbance are reported in 300 operations
on the genital tract.

The mental disturbance lasted from two to six weeks : three cases were
cured and three were not improved ; one of the latter committed suicide.
Two of the cases followed extirpation of the uterus, two castration, and
two washing out of the bladder. Ahlfeld reports a case of marked
mental disturbance following the introduction of a speculum.3 In a
paper read before the Dublin meeting of the British Medical Associa-
tion, August, 1887, by Dr. George Savage,4 of London, a number of cases
of insanity are reported following the use of anaesthetics in operations.
In some of the cases cited, the insanity is clearly due to the anaesthetic,
but in others the connection is not so clear, and traumatism as a cause
cannot be altogether excluded. Dr. Savage asks, " How long after an
operation may the effect of an anaesthetic be felt?" In certain oases, in
which days have elapsed before symptoms develop, it is hard to conned
the conditions ; but in many of these cases careful examination will reveal
that there was depression, drowsiness, or irritability from the first, so thai
although the maniacal attack had been postponed, the disorder started
at the time of the operation. In some cases Dr. Savage has seen death
follow from a condition resembling general paralysis of the insane.

In a case of surgical operation followed by insanity, in which an anaes-
t lift ie has been used, it is very difficult to say which was the exciting
cause, the traumatism or the amesthetic. It appears to me that trau-
matism has a much larger share in the production of the mania, for in
how many thousands of cases is an amesthetic given for purposes of
exploration and examination without any ill effects resulting. In all
the cases hut one. reported below, iodoform was used in small amount.

< Urit. M.mI. Jmirn., ftwmilUff 3, 1887.

» See ptipurby Harwell anddiecussion thereon at the London Clinical S.K-ioty, March 13, IMS ; Urit.
Med Journ., vol. I., I88.\

* Miinchener iiuxi. Wooh . Jam ■"•, ISM ; qaMti in Ivuioii leowM o§ Men. Bauaat, July. IMS,

♦ Loc. cit.

SHEPHERD, MANIA FOLLOWING OPERATIONS. 593

and on the surface only. In all the cases mania rapidly followed the
operation.

The cases of iodoform insanity that have been reported have usually
followed the use of large quantities of the drug for a considerable period
of time; hence I think that iodoform as a cause of insanity in these
cases may be excluded. Whether the anaesthetic had anything to do
with the occurrence of the mania I am not prepared to say. In Case II.
it had been used several times before without any ill result. In tw
my cases the patients had a distinct family history of insanity. In Case
V. the patient was an epileptic, and several of the family were likewise
affected. In Case III. no family history could be obtained, hut the patient
had always been queer and at times very excitable. Two of the cases
died maniacal, and one case never recovered complete sanity. In one
case pneumonia was a complication, and no doubt hastened death. Some
may say that the mania was produced by the pneumonia, but mental
disturbance was noticed before the supervention of pneumonia, and was
either due to the anaesthetic or the surgical injury, or to both causes
combined. Three of the cases followed operation on the abdomen and
its walls. Whatever was the cause of the mania in the cases reported
below, the fact remains that mania followed operation, and in three
cases with disastrous results.

Seeing that such serious results occasionally follow operations per-
formed on individuals who have'a strong predisposition to insanity, or
who have suffered from previous attacks, the surgeon should consider
whether it is advisable to operate on such individuals when the operation
is of no great argency, and is not essential to the prolongation of the
patient's life.

CASK 1. — I. B., merchant, at. fifty, first seen April 14, 1886, at the
request of Dr. A. A. Browne, had been ailing for some time, and for the
last ten days had been suffering from acute pain in the right iliac fossa
with elevation of temperature. Never had any rigors. The right i

i was excessively tender and could not be satisfactorily examined,
so next day patient was put under ether. Obscure fluctuation was felt
and pus reached with an aspirating needle. An incision was made same
three inches long immediately internal to the right anterior superior
iliac spine, and a deep dissection revealed an ahscess containing half a
pint of stinking pus and some small pieces of fecal matter; the ascend-
ing colon was seen at the bottom of the abscess cavity. The cavity
was washed out with a weak solution of carbolic acid, a large drain
introduced, and a small quantity of iodoform dusted over the wound.
Dressings were of washed gauze and sublimated jute. Next day patient
was doing well. The wound was dressed, and i few pieces of feces had
came through the tube; a small quantity of iodoform was again dusted
over the wound.

On the day following, patient had delusions, saw snakes and imagined
some one was coming to take him away ; he was with difficulty kept in
bed, and on one occasion escaped from the nurse and tried to jump out

594 SHEPHERD, MANIA FOLLOWING OPERATIONS.

of the window. Iodoform was stopped, and all that was possible re-
moved from the wound, and boracic acid substituted. Although there
were no tremors, both Dr. Browne and myself thought that the case mi
one of commencing delirium tremens, as the man was an immoderate
drinker. In a few days the delirium increased, and, in fact, the patient
became quite maniacal, necessitating constant watching by skilled
attendants. The delusions still continued ; he was very suspicious of
some plot to destroy him ; he always recognized his friends. During all
this time the wound progressed most favorably, and although the patient
ITOS weak, and lost considerable flesh and at times refused his food, he
went on fairly well. The mania lasted exactly one month until May
15th, when he suddenly recovered his sanity. By this time the wound
had completely healed. The patient has been perfectly well in his
mind ever since. A few weeks ago, both bones of the left leg were
broken by an accident, and fearing a return of his insanity I avoided
giving him an anaesthetic whilst putting up the limb Throughout this
last illness his mind has remained clear. The patient has a well-marked
family history of insanity : his father died in an insane asylum, and he
has an insane uncle and cousin; patient himself has always been subject
to ungovernable fits of temper.

Case II. — J. H., lawyer, set. twenty-seven, a strong, healthy-looking
man, for years had been troubled with necrosis of the lower end of the
left femur, caused by an injury when a boy. At times the thigh be-
came painful and swollen, when relief was afforded by the discharge of
pus through an old sinus in the inner side. At times, pieces of bone
came away. In the summer of 1885, I placed patient under ether
and removed a piece of dead bone. The wound was freely dusted with
iodoform. In a couple of weeks he went home perfectly well. He
came to me again on December 3, 1886, suffering acute pain in the
lower end of thigh and great tenderness on pressure at site of old sinus
on the inner side. His temperature was 100°. Pulse 120. On Decem-
ber 7th, assisted by Dr. Roddick, I cut down on the outer side of tin
lemur in search of the cause of the pain; no pus was found, but only
thickened periosteum and a sinus leading to rough bone. The patient
recovered well from the ether and said that the pain was much relieved.
The wound, 1 should have said, was dusted over with iodoform and
dressed with gaiue and sublimated jute.

Next day patient was very nervous, excitable and irritable, and could
not sleep. This condition continued till December Kith, when the kn
joint became swollen and was evidently full of fluid. His temperature
rose to 105°. Pus was now coming freely from the wound. As his
condition was unfavorable, he was again placed under ether and the
knee-joint aspirated, hut only serum was evacuated. An incision was
made in the inner Bide of the thigh at the site of the old sinus ; some pus
was let out and a through drain was introduced between the nv.'
wounds. Soon after coming out of the ether the patient became very

nervous, had tremors and delicious. In a day or two. the temperature
fell and the knee became quite normal in appearance, but his mental

condition became worse, lie became morose, would not answer when

spoken to, and fought whenever his thigh was dressed. He recognized
ybody, but was in mat fear, and was continually shrieking at the
top of his voice. He shouted single words as " Doctor." etc , tor hours
together.

SHEPHERD, MANIA FOLLOWING OPERATIONS. 595

By tin end of December his mania became furious, he was with diffi-
culty kept in bed and tried to bite any one who came near him. He
now failed to recognize his immediate relations. During all this time
tin- wounds in the thigh were doing well, and his temperature was
normal. He took nourishment fairly well, but having always been a
strict teetotaler he persistently refused stimulants. He became weaker
and weaker, and at last, on January 8, 1887, died of exhaustion. No
autopsy was allowed.

The patient had been physically very strong, and a good foot ball
player and athlete. His temperament had always been most excitable.
His (maternal) grandfather had had frequent attacks of insanity, and
committed suicide in one of his paroxysms. The amount of iodoform
used was very small, and was discontinued after the second day. In this
case, in which the operation was very trifling, the insanity may have been
induced by the anaesthetic.

Case III. — James B., aet. seventy-two, butcher, was admitted into the
Montreal General Hospital, July 10, 1888, suffering from a large
-trangulated inguinal hernia of the right side. The strangulation had
lasted three days, and stercoraceous vomiting had set in. Patient had
suffered from hernia for a number of years, and previously when it
became strangulated had always been able to reduce it himself. The
man was placed under ether, and, taxis failing, an incision was made
over the swelling ; the sac, which contained a quantity of bloody serum,

- opened, and the bowel, which was in fairly good condition, reduced.
The sac was ligatured and cut off, and the canal closed with a couple of
silk suture.-. The parts were painted with a solution of iodoform in
alcohol and dressed with washed gauze.

Patient recovered well from the operation, and next day passed flatus
freely. It was noticed, however, that he was a little queer; he got up
that night, wandered about, and helped himself freely to water from the
tap; his temperature and pulse were normal and the abdomen was pain-
less and flaccid. On the third day after operation he had a temperature
of 103°, and was quite delirious. On examining his chest, the base of
the right lung gave evidence of a commencing pneumonia. Next day
his temperature was lower, but he had delusions, and could with difficulty
be kept in bed. He insisted on tearing the dressings off his wound. His
bowels moved freely on the third day, and he never developed any
-ymptoins referable to his abdomen. He had some slight suppuration
at the upper end of the wound, which was a large one; this was, no
doubt, due to his constantly handling the parts and tearing off any
dressings which were applied. When I saw him on the morning of the
fourth day, he appeared fairly sensible, and agreed not to disturb the
dressings any more; but in less than an hour they were all torn away.
His mental condition kept getting worse, and on the tenth day aft»-r
operation his delirium was distinctly maniacal; he kept continually
shouting at the top of his voice and tried to bite anyone who came near
him. Hi- temperature was now normal and the pneumonia was resolv-
ing. At times the patient would refuse food, and again would drink
milk eagerly. Gradually becoming weaker, he died duly *2!'th.

At the post-mortem, the abdomen was found to be perfectly normal,
and there was not the slightest trace of peritonitis. The inguinal canal

Vli U IKS, SO. 6.— IlEI-CMBEB, l«8rf. ■

596 SHEPHERD, MANIA FOLLOWING OPERATIONS.

was closed, showing that the cure of the hernia was a radical one. There
was pneumonia at t he bases of both lungs. Brain apparently normal.
The portion of bowel which had been constricted was yet much discolored,
but in good condition.

I could get no history of insanity in this case, as his wife knew nothing
of his family, who lived in England. She said her husband was very
queer at times and often very irascible; he occasionally indulged to
excess in alcoholic liquors.

Case IV. — Mary M., servant, unmarried, set. fifty-one, was admitted
into the Montreal General Hospital in May, 1885, with scirrhus of the
left breast of eight months' duration. The axillary glands of that side
were enlarged. She had not been in good health for some time, and on
examining her urine, a large quantity of albumen and casts was found.
The breast was removed May 18, 1885, and the axillary glands dis-
sected out. She made a good recovery from the operation, the wound
healing in ten or twelve days. Soon after the operation she was noticed
to be a little queer in the head and had delusions, and these persisted
after she left the hospital. She never recovered from the mild form of
insanity then induced. Two years later, she died in the hospital of
cerebral hemorrhage. The scirrhus did not return. I could get no
family history of insanity in this case, as she had no relatives on this
side of the Atlantic.

Case V. — In January, 1886, Dr. George Ross asked me to see a case
of abscess, following typhoid fever, in a boy aged twelve. The abscess was
deeply seated in the lumbar region. The boy was placed under ether,
and a deep dissection made to evacuate the abscess, which seemed to be
in connection with the sheath of the psoas muscle. The boy, in a day
or two after the operation, became quite demented — in fact, was quite
silly. This lasted for several weeks, when he slowly recovered. The
abscess did well ; healed completely in two weeks. In this case the
demented condition may have been induced by the typhoid lever: but
still it did not come on until after the operation, which it closely followed.
The boy was an epileptic, and several of the family were likewise affected.

Case VI. — This case I saw in consultation with Dr. Gauthier, of
.Montreal. The patient was a woman, set. forty-five, and the mother of
several children. She had had a cellulitis of the arm. which had been
freely incised. Chloroform had been administered three times. She was
somewhat strange after each administration of the anaesthetic ; after the
last, during which several deep incisions were made, she became quite
insane. When I saw her, she was in good general condition — pulse and
temperature normal, and arm doing well. She nursed her arm under
the firm conviction that it was a baby. Although ordinarily a person
of the most retiring disposition, she now continually laughed, tang, and
danced, and kept asking us if we thought her crazy. several of her
near relatives had been very peculiar, and there were several drunk-
ards in the family, but, as far as I could learn, no distinct insanity. She
completely recovered her sanity some two weeks after I siw her.

In this case it is possible that the anaesthetic had more to do with the
mania than the operation.

SOLIS-COHEN, STRICTURE OF THE LARYNX. 597

STRICTURE OF THE LARYNX;

Willi KXTZN8IVI CI< YTRIZATIOX, FROM ULCERATIVE TUBERCULOSIS.1
I'.V J. Solis-Cohkn. M.D.,

Or PHILADELPHIA.

Mi:. X.. at. forty-five, of spare habit, scrofulous complexion, and nervo-
sanguine temperament, brought up as a farmer, but for more than
twenty years a machinist in charge of one of the most extensive foun-
dries in the United States, applied to me in September, 1887, for treat-
ment of difficulty in breathing, difficulty in swallowing, painful glutition,
and weakness of voice.

As received from the patient, his clinical history was briefly as follows :
Without any recollection of previous illnesses, during the winter of
1871-2 he acquired a very sore throat, more severe on the left side,
which hurt him extremely in swallowing. A swelling developed on the
left side of the neck just below the ear to the size of an ordinary peach
kernel, and softened into an abscess which was opened, and which re-
mained open for about six weeks. As this swelling had increased in the
neck the sore throat had improved, so that it had gotten well before the
abscess was opened. The voice had not been in any way affected. In
the winter of 1883-4 he had an attack of bronchitis following an acute
corvza, but recovered thoroughly. In February, 1886, while perfectly
well, exposure to cold brought on acute inflammation of the throat with
dysphonia and dysphagia. This subsided under constitutional and
topical medication in about six weeks, the voice becoming entirely
normal.

One year later, February, 1887, after exposure to cold, a much severer
attack of sore throat ensued, the dysphagia being much greater than
before. By May the inflammation had subsided very much, and the
voice had almost resumed its natural character. In the middle <»t May
tin- soreness began to increase and the voice failed. This condition, with
some improvement in strength of voice, but never complete freedom
from huskiness, prevailed until the date of application to me. On close
questioning, I learned that the patient had never been able as a boy to
take part in games that required running. His wife assured me that,
though strong in every other way, he had been a little short of breath
on exertion, and had a weak voice ever since she had known him ; that
in December, 1877, he had had a severe sore throat for two weeks with
chokings at each meal, after recovery from which he had no trouble
until February, 1886 ; that he began to breathe with difficulty in May,
1887, and in June began to cough and choke in swallowing liquids.
The patient had lost twenty-four pounds in weight within six months,

til before tie American Lan ngolofcical Asuocimi. n, 1889, and the larynx and trachea exhibited.

598 SOLIS-COHEN, STRICTURE OF THE LARYNX.

despite a summer sojourn in the Adiroudacks which had so improved
his general strength that, from having been hardly able to walk on his
arrival, he had become able to walk three or four miles at a stretch with-
out fatigue and without dyspnoea.

On examination of the throat, I found a condition that I had not met
before. At the root of the uvula, extending half an inch along each
side the soft palate, was a pale, bilateral, symmetric cicatrix, broad at the
raphe and gradually acuminated toward each extremity, of the same
physical appearance as the cicatrices of syphilis. The epiglottis was
gone ; the cicatrized stump presented the same pale, glistening aspect
as the cicatrix in the palate, and it was continuous into similar-looking
tissue on either side, which represented thickened pharyngo-epiglottic
folds. The top of the larynx looked as though overlaid by a thick,
tense, uniform diaphragmatic membrane, which, without evidence of
cicatrices at any point, left a small pear-shaped orifice in the centre ;
the butt in front and the apex in junction posteriorly (Fig. 1). The
largest horizontal diameter was about three mm. at the butt, whence it
tapered to a point at a distance posteriorly of about six mm. Through
this membranous-looking structure the exterior outline of the aryteno-
epiglottic folds could just be made out.

The parts were pale. Their appearance was quite similar to the pic-
ture of lupus of the larynx figured in the last edition of Lennox
Browne's volume {The Throat and its Diseases, London, 1887, p. 398,
pi. xiv. Fig. 119). There was no history of syphilis, nor had I any
reason to suspect infection.

The picture was the picture of lupus ; the cachexia, the cachexia of
tuberculosis ; the diathesis that of scrofulosis.

There was evidence of disorganization going on in much of the left
lung and in the upper portion of the right one. The sputa, which were
ejected with difficulty accompanied by a sort of sneeze of the glottis, if
I may so describe it, were decidedly tuberculous.

The conclusion I arrived at was that this was a case of congenital
syphilis which had become cured with slight defect in the soft palate,
loss of the epiglottis, and adhesions between the upper surface.- of the
ventricular bands which, with the aryteno-epiglottic folds had become
stretched into a sort of diaphragm. The closest scrutiny with the
• •xyhydrogcn light and with magnifying mirrors did not disclose any
trace of a cicatrix in this diaphragmatic tissue. Hence there was some
suspicion that this formation might have been congenital and that con-
traction had taken place of late years in consecpieuce of recent intlam-
nuitions or of irritation set up by the tuberculous process.

The difficulty in swallowing liquids was readily overcome by adopt*
Ing Wolfenden's suggestion of swallowing in the prone position from a
tube in ii tumbler. My patient, who was a machinist, explained the

SOLIS-COHE.V, STRICTURE OF TH1 LARYNX. 599

mechanism by a sort of siphonage, making one continuous conduit of
the rubber tube, the back of the throat, and the oesophagus, without
impingement of the liquids on the superior surface of the larynx, the
efforts at swallowing keeping the liquids in line.

As to relief for dyspnoea, the choice wavered between tracheotomy and
section of the constricting tissues. It was determined to try the latter first,
as tracheotomy could always be resorted to in an emergency. I began
by dilating with the Schroetter's tubes. At first there was difficulty in
introducing the smallest, No. 1 ; but at the end of about three weeks I
was able to introduce No. 10, although the orifice closed up a little after
its withdrawal. It did not contract, however, beyond the calibre of N<>.
•">, and this passage gave me ample room, under oxyhydrogen illumina-
tion, to see that the vocal bands were free to move in efforts at phonation.
In the belief that the diaphragm was composed of the tissues normally
represented by the aryteno-epiglottic folds and ventricular bands, I
had a special pair of scissors made to cut the fold ; but on trying them
found, to my surprise, that the tissue was so thick that I could not get
a purchase. I then resorted to the naked knives presenting in the car-
dinal directions, which for more than twenty years I have been using to
divide strictures of the larynx ; and by sawing through fully half an
inch of solid tissue, almost cartilaginous to the touch, beginning in the
direction represented in the dotted lines in Fig. 1, I succeeded, in the

Fig. 1.

m */

Stricture of the «operior orifice of the larynx.

course of several days, in modelling a very fair representation of what I
thought the normal arytenoepiglottic folds ought to be. Several pieces
were thus sawed out solidly. Some were examined microscopically in
Philadelphia, others in Washington by Dr. W. If. Gray, of the United
States Army Medical Museum. Dr. Gray wrote me that he cut the largest
piece only, not thinking it worth while to examine the little pieces
unless specially requested. The specimen contained many bacilli, some
of them in large giant cells. Dr. G. de Schweinitz, of Philadelphia,
found in the sections he examined a somewhat thickened epithelium,
beneath which was a granulation-like tissue, with occasional giant cells
and numerous tubercle bacilli.

After the posterior adhesions had been divided and the resection of

600

SOLIS-COHEN, STRICTURE OF THE LARYNX.

the lateral parts had been effected, the picture assumed the ordinary
aspect of tuberculosis of the larynx.

There was no disposition to retraction, and the operative wounds in
a great measure cicatrized, although the wedges of tissue excised had
contained numerous tubercle bacilli. This cicatrization was spontaneous.

The subsequent clinical history was the usual one of tuberculous
laryngitis, and the patient died with pulmonary oedema in the latter part
of February, 1888.

Examination twenty-five hours after death showed both lungs tuber-
culous ; the apex of the left one being riddled with small cavities, and
the base of the right lung being healthy. The larynx showed very great
thickening of the aryteno-epiglottic folds and ventricular bands, with
detachment of the fibrinous portion of the vocal bands from the mus-
cular portion, the intervening tissue having cicatrized. Both arytenoid
cartilages were carious and exposed. The raw surfaces of the cuts made
in resection were in great measure cicatrized (Fig. 2).

Fig. 2.

Tim liirynx oxjvwed posteriorly.

The specimen has been preserved for future roferenee.s in the United
BfeUei Annv Medical Museum. Washington.

REVIEWS.

(i.i mi ax Lectures ox Important Symptoms. By Thomas Grain

fART, M.I>. Edinburgh; Professor of the Practice of Physic and of
Clinical Medicine iu the University of Edinburgh. Fasciculus II. Ok
Albuminuria. 8vo. pp. 249. Edinburgh : Bell & Bradfute, 1888.

ars have elapsed since the first fasciculus of the author's
ires on Important Subjects was published. The symptom
treated of in that series was "Giddiness." Professor Stewart informs
us in the preface that the lectures comprised in the present series have
been delivered at various times during the past two years, and that, as
we well recall, several of them have appeared in the journals. They
embody his present views regarding the chief clinical questions dis-
cussed in his book on Bright'* Diseases of the Kidney*, the second edition
of which has been for many years out of print, and to some extent,
therefore, fulfil the desire of the profession that he should issue a third
edition of that work. But they fulfil it to some extent only, seeing that
they approach the subject exclusively from the clinical side. We desire
the mature views of the author upon the whole subject of the diseases
of the kidneys, their causation, their pathological histology, their natural
history, their relationships to other pathological states, both local and
general, their treatment and prevention, their termination, and their
pathological and clinical classification ; and for this reason we may still
look forward to the appearance of a third edition of the author's work.
Meanwhile, we gratefully accept these lectures. They are eminently
practical and instructive. There is a certain advantage in thus tracing
:nptom, common to many derangements, hack to its various sources.
It helps to all-around views of a subject. One thinks of the shield in
the fable, one side of which was gold, the other silver. He who has
passed it adds to his knowledge of it by retracing his steps to look on
it :iLrain.

They are, to a great extent, based upon original work undertaken to
solve mooted questions in the etiology and symptomatology of diseases
of the kidneys, and represent an amount of labor not on first considera-
tion apparent to those who have not undertaken similar studies.

A list of the various forms of albumen and allied substances found
in the urine and the tests for them, is followed by a critical >tudy of the
relative delicacy of the tests for serum-albumen. The author does not
employ the word albumin, as is now commonly done, to designate serum-
albumen.

The results show that the boiling ted, carefully applied, is an excellent
one, revealing the presence of so little as 0.00218 of a grain per ounce,
and that heat, with the previous addition of a little acetic acid, is still
more delicate, showing 0.00131 of a grain per ounce.

602 REVIEWS.

The cold, nitric acid test is of inferior delicacy, not giving a distinct
reaction with less than 0.01311 of a grain of albumen per ounce.

/ iarie acid proves the most delicate test, giving a faint, but perceptible
reaction up to 0.00015 per cent., or 0.000655 of a grain per ounce.

We are fully in accord with the author, however, in regard to the
relative value of the various tests, namely, that it by no means coincides
with their sensitiveness. The more delicate of them are to be used with
caution ; little importance is to be attached to faint indications obtained
by their use, and albuminuria is rarely a serious condition unless it is
sufficiently pronounced to be made out by the cold nitric acid test.

We gather from the context that Professor Stewart is in the habit
of using the cold nitric acid test and controlling it, when no reaction
is obtained, by the more delicate test of picric acid.

For the quantitative analysis of albumen, the author's experience
coincides with that of Dr. George Johnson, namely, that Esbarh'.<
method, as compared with Sir William Roberts's dilution process and the
percentage method of Dr. Oliver, possesses the advantage of greater ac-
curacy, yielding results more closely corresponding to these obtained
by the elaborate drying and weighing process, which is not available
for ordinary clinical work.

An elaborate series of investigations undertaken to determine the
frequency of albuminuria and the circumstances under which it may
occur in persons apparently healthy, gave results which the author
formulates as follows :

" 1. That there is no sufficient proof that albumen is normally discharged
from the human kidneys.

"2. That albuminuria is much more common among presumably healthy
people than was formerly supposed, being demonstrable by delicate testa in
nearly one-third of those examined.

" 3. That the existence of albuminuria is not of itself a sufficient ground
for the rejection of a proposal for life insurance.

" 4. That traces of albumen are not infrequently present in the urine passed
during the first days of life.

"5. That, excepting as shown above, the frequency of albuminuria in-
creases as life advances ; being rare in children and young adults, and common
in men at or above sixty years of age.

"6. That it is more common among those whose occupations involve
arduous bodily exercise than among those who have easy work.

" 7. That albuminuria frequently follows the taking of food, especially of
break fast

"8. That moderate muscular effort rather diminishes than increases albu-
minuria, except in ran eases.

" 9. That violent or prolonged exertion often induces albuminuria.

"10. That cold bathing produce! or increases it in some individuals.

"II. That the discharge of peptones from the kidneys is exceedingly rare
in the presumably healthy. "

A similar series, undertaken to determine the incidence of albumin-
uria among the sick, resulted in the conclusions embodied in the following
statements:

" 1. That as in health, so in disease, albuminuria is much more common
than is generally supposed.

" •_'. That it is more common among patients of adult age than among

children.

8, That eases of Bright's disease do not account for one-half of the cases
of albuminuria met with in practice.

STEWART, CLINICAL HC 608

• 4. That they account for more than any other individual cause.

Thai next to them rank cam induced by cardiac and other maladies
affecting the circulation, and those due to tin- accidental admixture of blood,
pus. or other albuminous fluid with the urine.

" <■. That so Car as this series of observations shows, the various forms of
funetional albuminuria are rare.

"7. That in waxy and eirrhotic diseases of the kidneys, the quantity of
albumen is at first so slight as to be shown only by picric acid.

"8. That u-ually in these when advanced and in renal inflammation, the
albumen is more abundant than in other varieties of albuminuria.

" 9. That in the digestive and nervous cases, and those due to high tem-
perature, the quantity is often so small as only to be discovered by picric
acid."

The author sums up a most discriminating review of the theories
in regard to the pathology of albuminuria, in these words :

• I would have you believe that albuminuria is very often due to changes
of an inflammatory character in the epithelium of the tubes and in the stroma
of the organ, and that in a very large proportion of the cases in which it
occurs in practice it is dependent upon this cause; that increased blood-
mure is a factor of some importance; that increased permeability of the

filtering apparatus induces it in many instances; and that there may be some
conditions of the blood which account for it or favor its occurrence."

Then follow lectures upon albuminuria from inflammation of the
kidney, from cirrhosis of the kidney, from waxy or amyloid degenera-
tion; all abundantly illustrated by cases drawn from the author's rich
experience in this field of clinical work.

Equally interesting and important are his views concerning the albu-
minuria from fever and other causes; but it is to the lecture upon those
albuminurias which have been designated variously by different writers
as functional, intermittent, dietetic, cyclical albuminuria, and the albu-
minuria of adolescence, that those familiar with the subject will turn
with especial interest. Here is a field that our author has tilled with a
diligence his own.

Four categories may be distinguished with advantage. There are,
first, paroxsymal albuminuria; second, dietetic albuminuria; third,
albuminuria from muscular exertion; and, fourth, simple persistent
albuminuria. These forms may run into one another and mutually
overlap; they may succeed each other in the same individual from time
to time; they may and they frequently do occur in individuals who
otherwise have excellent health, and they may vanish altogether, or
may recur from time to time for years without entailing serious conse-
quences. But the prognosis is not in all cases so hopeful. The author
admits that the culmination of such cases in organic disease of the
kidneys does occur, but thinks it must be rare. Dr. George Johnson
and Dr. ( lenient Dukes believe that a proportion of the cases of par
ysmal albuminuria are either Bright's disease in its incipient stages, or
ultimately run into that condition.

In view of this possibility, paroxysmal albuminuria must be regarded
as a significant, often as a serious symptom.

M'>xon's paper in fhiys Hoep&al Reports appeared in 1878 ; the greater
part, in fact all the exact investigations into this <rroup of albumin-
urias have been made since this date; Pavy's article on cyclic albu-
minuria was published in 18*."). The subsequent history of many of
the cases is too brief as yet to warrant positive assertions in regard to

tiOl REVIEWS.

the whole clinical course of these forms. When the time for this shall
have elapsed, the group of "albuminurias not dangerous to life" will
probably appear smaller than at present.

Accidental albuminuria is next briefly discussed. Then follow lectures
upon the differential diagnosis aud the prognosis in albuminuria, on
diet, and on the effects of medicines. The author's observations on the
subject of prognosis are very practical and suggestive ; his views on the
effects of various diets are based upon exact investigations, and, there-
fore, possess a positive value as compared with the vague statements
current in textbooks ; the same may be said of his conclusions in re-
gard to the power of medicines in controlling the output of albumen by
diseased kidneys —

" I have satisfied myself, by a long series of careful observations, that we
have no right to credit any drug with the power of directly diminishing the
discharge of albumen."

This is, at present, the opinion of observant physicians at large. Yet
it must not be looked upon as a pessimistic view of the subject. To
abandon the effort to diminish directly the loss of albumen by drugs,
an effort shown over and over again to be useless by the ablest thera-
peutists, and devote their energies to methods of treatment abundantly
proved to be of general benefit to the patient and so indirectly favorable
to the course of the renal affection is, in fact, a wholesome gain in the
management of these diseases.

In regard to climate, the author writes :

" In the mixed forms of organic renal disease, the treatment must be deter-
mined according to the preponderating element. In all of them, whether
combined or not, the choice of climate is of much importance. When it is
possible, these patients should avoid cold and damp districts. It is well for
them to winter in the south of Europe, in Algiers, or in Egypt; and practi-
tioners in high altitudes, such as Davos, find that renal cases should not try
treatment there. The only exception to this rule is afforded by purely waxy
cases which have resulted from chronic phthisis, and in which the advantage
to be derived, in respect of the pulmonary disease, tells favorably upon the
kidney also."

The arrangement of the data and results of investigations in the form
of tables constitutes a valuable feature of the book, and saves space
and needless repetition.

In conclusion, we regard these lectures in their present form a- an
important contribution to the literature of clinical medicine in tin-
broadest sense. J. C. \V.

Essays on II ystkria, Rrain Tumor, and some other cases of Ni r.vous
I'i-kase. By Mary Putnam Jacobi. 8vo. pp. 20S. New York: <;. P.
Putnam's Sons, 1888.

In this little volume, Dr. Jacobi has brought together seven in:
tag essays, elsewhere published, on various forms of nervous disease, the
two subjects mentioned in the title occupying two-thirds of the book.
The work is noteworthy from its careful preparation, diligent search of
literature, familiarity with the subjects treated, considerable practical

LAWSOX. VKLLOW FEVER AND CHOLERA. 605

erienoe in nervous diseases combined with powers of keen observer
tion, and is made attractive by its clear style.

The writer believes that in hysteria there is ;; tal or acquired

deficiency in the power of the nerve elements to eneet the .-:
force in nerve tissues, resulting in morbid limitations of Amotion. And
that further the normal balance of action between sensory and motor
nerve elements is interfered with, producing as a result increased inhi-
bition on one side and hyper-sensitiveness on the other. The seat of this
disturbance is the cortex, and vaso-motor instability accompanies and
possibly causes it. In this view the influence of Meynert upon the
author's line of thought is evident; the hypothesis of a correlation
between cortical and subcortical action and blood supply being accepted.
Many interesting facts are gathered in apparent support of this view
of hysteria — which certainly is a fairly satisfactory one.

As a basis for the essay on brain tumors the writer has brought
together over tive hundred cases from foreign literature, and, therefore,
the tables and percentages are very valuable. Such facts as the absence
of headache in one-half of the cases of tumors of the cortex, the infre-
quency of vertigo and vomiting in tumors of the frontal lobes (18 per
cent.), the occurrence of choked disk in only 22 per cent, of 362 cases ;
the greater frequency of this symptom in tumors affecting the base of
the brain than in other locations, the greater frequency of mental symp-
toms in tumors of the centrum ovale (60 per cent.) than in those of the
cortex alone ( 49 per cent. ) or frontal lobes alone, are very important
aids to diaguosis. The discussion of focal symptoms is admirable, the
section on paralysis and spasm being very clear. Differential diagi:
is not fully discussed, the possibility of nephritis or hysteria being mis-
taken for tumor not being mentioned. The chief criticism which may
be made Ls that too much stress is laid upon the statistical consideration
of single symptoms and too little importance attached to their combi-
nation in individual cases.

The remaining essays on the loss of nouns in aphasia ; on rotary
spasm; on the prophylaxis of insanity; on the antagonism betw
remedies and diseases, and on hysterical locomotor ataxia will interest
the neurologie M. A. 8.

Tin: Milroy Lectures ox EpxdbhiO Ini i.t i.n< i:-. Ox thk 1>ii>i:mi<>-

LOGICAI. ASPBGT8 OF VkI.I.oW I'l.VKIl. Ol till: Kl'IDEMIOLOGICAL

A-iKCTS of Cholera. By Robert Lawsox, LL.D., I n-pi (-tor-General
of Hospitals; Late President Epidemiological 8 • How Statistical

Society. 8vo. pp. 95. London: J. & A. Churchill, 1888.

Tin> volume contains the first of a series of lectures to be delivered
under the bequest of Dr. Gavin Milroy, who left a sufficient sum to the
Royal College of Physicians of London to endow an annual course of
lectures on state medicine and public hygiene.

The selection of Dr. Lawson to inaugurate the course of lectin- -
fitting compliment to an experienced observer in the field of epidemi-
ology, and most appropriate, as he was well acquainted with the f
of Dr. Milroy. with whom he had been very intimate for many y

606 REVIEWS.

The choice of epidemic influences as the theme for the opening course
" was made under the impression that it would have met with his
approval, and that it really constitutes the first step in the investigation
he desired."

It has long been recognized that there exist certain factors inti-
mately concerned in the diffusion and intensification of disease, from
time to time, which are not referable to individuals or localities, and
which factors have often been vaguely referred to by the conventional
terms of ''epidemic constitution," "epidemic influence," and "pan-
demic influence." Of the nature and mode of operation of thtse
factors, little is definitely kuown. But we must recognize their ex-
istence and endeavor to become acquainted with the conditions under
which they operate. It is for this object that Dr. Lawson has undertaken
the task of collating facts, made available by long experience and close
investigation, which he conceives to have an important bearing upon
our knowledge of the spread of epidemics.

A study of these facts shows that the epidemic factors embrace large
portions of the earth's surface at the same time, and that their course
from year to year is somewhat definitely defined. With regard to
febrile epidemics, which are discussed in the first chapter, he holds that
when developed at various points, from time to time, they passed uni-
formly to the northward until they finally disappeared. They recur
fteriodically every second year, or at some multiple of two years, and
ike a series of waves pass over a more or less extensive portion of
the earth's surface. These waves he has named pandemic waves, but as
to their nature nothing is known at present. As their position from
year to year seems defined by lines of equal magnetic dip, he infers that
they may be dependent in some way on that force. In order to illus-
trate this idea he has constructed a map on which the surface of the
globe is divided into zones, marked out by iso-clinals, a plan which
affords to epidemiologists a means of arranging the complicated mass of
details at their disposal.

In pursuing the subject of epidemic influences, Dr. Lawson lias col-
lected in the second chapter a large amount of authenticated data relat-
ing to epidemics of smallpox, yellow fever, and the plague, which have
prevailed from time to time in various portions of the globe. These
data, besides furnishing an outline of the histories of notable outbreaks
of disease, enable the student of epidemiology to investigate their
development, the mode of their extension, and their limits as to time and
space, with the view of determining, if possible, some general law under
which such manifestations arise.

From the details given it would appear that smallpox, which some
believe is independent of all extraneous influences save the presence of
a virus and the receptivity of its subjects, is, like fevers, under M the
influence of a pandemic factor which determines its development as an
epidemic in some places in the first instance, and its subsequent exten-
sion to the northward in successive years." These pandemic waves
appear every second year for the most part, or at some multiple of two
I-. though by the following <»t' one wave upon another there is some-
times tin appearance of an epidemic of three or four consecutive years.
As before remarked, nothing is known of the true nature of this factor
DOT of its course from south to north, and of its observing a two yearly
period.

LAWSON, YELLOW FEVER AND CHOLERA. 607

Dr. Lawson has collected facts to show that under the influem ■<■ of
the nine pandemic wave different forms of fever arise in diflerent
localities, from which he infers that there exists the operating fore
additional factors. Thus, fur example, in places where remittent or
continued fever are the common fevers, yellow fever makes its appear-
ance at intervals of a considerable number of years, when there existed
no trace of it, indicating that there is a special factor leading to the de-
velopment of this disease in a locality where the circumstances are suit-
able. These latter embrace states of the weather, conditions of the
soil, especially that of moisture, and the presence of the particular
miasm which engenders the disease.

The study of the various outbreaks of the plague shows that epidemics
<>f this disease, like those of other fevers, are subject to a force which
determines their wave-like mode of progression in the same direction,
the outbreaks occurring, for the most part, in the first year of a pan-
demic wave, with recrudescence the following year.

Facts seem to indicate that the appearance of the benign plague is
due to a separate factor concurring with the pandemic wave. Whether
this form of the disease presages the appearance of the plague in it-
more intense form and this is its usual course, or whether the severe
form is merely an intensification of the benign form, due to circumstances
temporarily existing, the factor remaining the same, are questions which
present investigation fails to determine.

In tracing the course of epidemics chronologically over extensive
portions of the earth's surface and noting their rise, mode of progres-
sion, and decadence, Dr. Lawson observed that their movement was due
to a factor which appeared to be of very general operation, and most
likely connected with some of the natural forces. Careful investigation
showed that this movement was approximately defined by lines of equal
magnetic dip, and he, therefore, inferred that it may be dependent upon
that force. Whether the theory here presented be accepted or not, Dr.
Lawson must have the credit of having brought together a large number
of facts showing the concurrence of phenomena indicative of the uni-
form action of some natural force or cooperation of forces, which may
lead to further progress in the study of this abstruse subject.

The third lecture on the epidemiological aspects of yellow fever
will be read with interest at the present time, in view of the prominen<e
given to the subject by the recent outbreak of the disease in Florida.
Alter having described yellow fever, the author proceeds to a considera-
tion of its cause. The moot question is whether yellow fiver prevailing
in a locality more or less circumscribed arises from the operation of
causes originating in the locality at the time, or whether the disease
must have been brought by one or more persons from a locality where
it was prevailing, and by them communicated toother persons; in other
words, Is yellow fever a contagious disease, or is it of miasmati< origin,
depending on causes existing in the place in which it appears, and de-
void of contagion ? A close analysis of a large number of notable
outbreaks of the disease, especially on ships (where the opportunity for
studying the facts is most favorable', has led Dr. LawtOO to adopt the
theory of the local or miasmatic origin of yellow fever ; for, as he re-
marks, to accept the view of its contagiousness involves the exclusion of
local causes, which the bulk of evidence used to support this theory does
not permit of.

608 REVIEWS.

According to Dr. Lawson, cases of yellow fever imported to a healthy
locality are incapable of communicating the disease, but a vessel may
have the active source of yellow fever produced in her and carry it to a
distance. A ship may be iooked upon as a locality, like a circumscribed
space on shore, and may acquire the conditions for producing yellow-
fever without communication with a previous case. The vessel being
movable, may communicate her febrific powers to a great distance, but
it cannot infect a healthy locality unless the local circumstances are
favorable. Persons coming in contact with the vessel, or within range
of the emanations from her, may contract the disease, but the disease
will not affect persons on shore who have not thus exposed themselves.
Another fact of significance is that the disease does not spread on ship-
board from persons who have contracted it in an infected locality, when
the vessel is free from the conditions suitable for generating the active
cause of the disease.

A study of the histories of epidemics of yellow fever at Bermuda,
would seem to prove that these visitations occurred without any pre-
vious introduction of persons suffering from the disease. The outbreaks
on the "Susquehanna" and "Orion" in the West Indies, in 1857, also
furnish evidence to sustain the same conclusion. It is, therefore, held
that importation is not a necessary factor in the conditions required for
the development of yellow fever.

As to the cause, it is believed to be particulate, a living miasm, devel-
oped under certain climatic and terrestrial conditions and capable of
being diffused by the air. The potential factor can be air-borne, even over
extensive areas, but until it meets with a suitable soil for its further de-
velopment, such as the hold of a ship or a locality favorable to its pro-
duction, it is incapable of giving rise to the disease.

If the above views be accepted, it follows that land quarantine against

{>ersons from a locality where yellow fever is prevailing is not only use-
ess, but an unwarranted interference with personal liberty ; and the in-
discriminate and prolonged quarantine of vessels from fever ports, by
ignoring the fact that vessels may have cases of yellow fever on board
without being iufected, is a restriction based on a want of knowledge,
which imposes a needless obstruction to commerce without being of any
advantage to the public health. It must be remembered that Dr. Law-
son voices the English views on this subject, which are opposed, in tin*
main, to quarantine, but which favor, in its stead, a system of " complete
sanitation.''

That yellow fever is not communicated directly from person to person,
that the seeds of the disease are not reproduced in the human organism
and migrate from it to other persons, is generally accepted. As a ship
may be looked upon as a locality which is capable of acquiring the con-
ditions necessary for producing the disease, it is possible for it to carry
the infectious material to distant ports where, under favorable terrestrial
and climatic influences, it maybe reproduced and give rise to an epi-
demic.

The fourth lecture is devoted to a brief consideration of the "epidem-
iological aspects of cholera." Various opinions regarding the causa-
tion of cholera are presented, and the distinction between cholera nostras
and malignant or Asiatic cholera fully described. The occurrence of
eholera in any locality, if the persons attacked have not been away from
tlie locality, indicates that the cause of the disease is in operation there :

LAWSoX. YELLOW FEVKK AM' CHOLERA. 609

but, according to l>r. Lawson, "before the ap|>< Branca of the disease in
the locality can be attributed to communication from a previous

which had ariaen elaewhere, it is nncinaairj t.. exclude the influence of

local causes." Be further remarks, that "there are now on record a
i many inatancei of even extensive epidemics of cholera, which hroke
out at points tar removed i'rom any place where the disease was already
in progress, and without any trace that could be detected of importation
by man or fomitea." The outbreaks in England in 1865 and in America
in 1<S7-1 are [riven as examples of such epidemics. " Epidemic influence
coinciding with local conditions" is thought to explain these outbreaks.
An eruption of cholera in a locality subsequent to the importation to it
of persons Buffering from the disease does not, in his opinion, warrant
the assumption that it has been communicated by such persons, unless
the local cause be excluded, which, in most cases, the evidence does not
permit of being done. Dr. Lawson believes that the manifestation of
cholera in localities far removed from where the disease prevails without
the intervening population being affected by it, as in the epidemics in
Syria in ls7-~>, or upon ships in mid-ocean, as in the cases of the " New
York " and the "Swanton " in 1848, may be ascribed to the transport
of the exciting cause by currents of air at some elevation in the atmos-
phere.

The opinions of authors are cited who believe that the disease is diffused
from endemic areas by the influence of the winds; and those of others
who hold that it frequently progresses against the wind and who, there-
fore, believe that the extension of epidemics is due to a considerable ex-
tent to communication from man to man.

A relation is supposed to exist between cholera nostras and malignant
cholera, inasmuch as a study of the records of these diseases in different
countries shows that the former disease increases in frequency and
fatality in advance of an epidemic of the malignant form and moderates
as the epidemic passes on ; and this characteristic is of sufficiently fre-
quent occurrence to be made use of in predicting an outbreak of malig-
nant cholera.

In reference to cholera on board ship, it is remarked that a ship lying
in an epidemic port may be regarded as a part of that locality which
may become a focus of cholera, but, unlike a place on shore, can carry
the active source of the disease to a great distance. It is possible for
cholera to develop in persons on board a healthy ship who have been
exposed to its cause on land or at sea. yet when the vessel is removed
from the source of the disease by a change of locality, fresh cases of sick-
ness usually cease after a few days. In the one case there exists the
morbific agency together with conditions favorable to its further develop-
ment, in the other these conditions are absent.

Without disparaging the views of Dr. Lawson on a subject concern-
ing which there is room for a difference of opinion, it may be remarked
that the general belief is that cholera is due to a germ, which being re-
ceived into the alimentary canal gives rise to the manifestations of the
disease. While the germ multiplies in the bowels and is principally
contained in the alvine excretions — which under suitable conditions may
spread the disease — it is chiefly in fluids extraneous to the body that it
develops, and hence it is that drinking water and ground-water play
an important role in the distribution of the disease. The germ may
also be diffused by the air, by clothing, bedding, and by attaching itself

610 REVIEWS.

to solid substances. Great humidity of the soil and an accumulation of
ground-water in its superficial layers are believed to be important breed-
ing factors of the cholera germ. The conditions for the development
and diffusion of cholera are a favorable medium for the multiplication
of the germ, sufficient contact with the human organism, and personal
susceptibility. Climatic conditions doubtless have a modifying influence
on the spread of epidemics. The idea that cholera epidemics pursue a
definite course from east to west has been for the most part abandoned,
and it is now the current belief that the disease is spread by human
agency, by the lines of traffic, through cases attacked, whose effects,
emanations, stools, carry the morbific agent and transport the disease,
particularly when the conditions of the ground-water, drinking-water,
and their contact with human beings favor the development and action
of the germs.

The theory that cholera is autocthonous, and may arise under epi-
demic influence independently of a germ, cannot be sustained by the
evidence at hand. Very little importance need be attached to the
theory that cholera is spread to great distances under certain conditions
of the atmosphere and with the winds.

Dr. Lawson's book is well worthy of perusal. It contains an impos-
ing collection of facts which have an important bearing on the spread
of epidemics, with such generalizations as the evidence at hand have per-
mitted him to make.

His views upon the epidemiological aspects of yellow fever and cholera,
especially the latter, should be read in connection with the works of
recent investigators, whose opinions in some important particulars are
at variance with those which he advocates. W. H. F.

The Electric Illumination of the Bladder as a means of Diag-
nosis of Obscure Vesico-urethral Diseases. By E. Hurry
Fenwick, F.R.C.S., Surgeon (Out-patient) to St. Peter's Hospital for Stone
and other Urinary Diseases ; Assistant Surgeon to the London Hospital ;
Examiner in Elementary Physiology in the Conjoint Board in England of
the Royal Colleges of Physicians and Surgeons; Assistant to the Lecturer
on Physiology at the London Hospital Medical College. With thirty
illustrations. 8vo. pp. 176. London : J. & A. Churchill, 1888.

Tin. appearance of this excellent and praiseworthy monograph is v» in-
opportune. Heretofore, there has been no demand or want for such a
work as this, which is destined to create that want, simply because the
general profession, or even specialists, have scarcely yet had time to be-
come aware of the marvellous capabilities and practical advantages of
tlir beautiful cystoscopy and mvthroscopes which have recently been
brought to such great perfection by Nit/.e, of Berlin, and Leiter, of
Vienna. We had the pleasure of witnessing the accurate working! of
these two instruments, shortly | in it their introduction at Berlin, a year
unce, end it i- a matter of greed regret that the use of such vmluebk
adjuncts to diagnoetic research are not yet in general use.

The work i> cleverly written in a clear, attractive style, and the

FENWICK, ELECTRIC ILLUMINATION OF BLADDER. 611

author's enthusiasm is kept rigorously in check by the confines of fact,
and lie has had a very large experience in the use of these instruments
and with disorders of the vesico-urinary system. It will undoubtedly
add to the reputation of the author and demonstrate to the profession
that they have now within their reach one of the most valuable addi-
tion? to our armamentarium of instruments for the purposes of diagnosis
and direction of accurate treatment that have been introduced since the
ophthalmoscope and laryngoscope.

Bearing in mind the acrimonious dispute between Nitze and his in-
strument maker, Leiter, Mr. Fenwick has been careful not to enter into
the merits of that dispute further than to quote from the actual litera-
ture of the subject and to avoid all invidious distinctions, save that he
considers the ideas of these two men as so closely interwoven in the de-
velopment of the perfected instruments, that the name of either variety
:ld be " Nitze-Leiter ; " placing Nitze first, as it was he who first
conceived the idea of illuminating the bladder ; whilst to Leiter cer-
tainly belongs very great credit for its ingenious working out.

Chapters 1., II., III. are devoted to an exceedingly interesting history
of the evolution of endoscopy, from the first introduction of the method
of visual exploration of the cavities of the human body by Nitze in
1 s79, through the period of the incandescent platinum loop and cooling
apparatus, to the beautiful Nitze-Leiter electric-light cystoscope of 1887.
He regard? the far-famed but discarded cvstoscope of 1879 as having
same relation to that of 1887, as has the "Puffing Billy" of
henson to a modern locomotive, yet he does not believe that the in-
strument is even now perfect, but that its working has come to such a
practical point as to make it an indispensable factor in the diagnosis of
diseases of the urinary tract.

The following twenty-five pages clearly and minutely describe the
method of using the cystoscope, give several series of rules for the same
purpose, enumerate the various physical and other requirements for
successful exploration of the bladder, and end with a beautiful de-
scription of the picture which can so easily be had of the normal
bladder through the electric cystoscope. Then succeed fifty pages of
equally readable and instructive matter describing the appearances of
the bladder pathologically changed by inflammation, tumors or when
harboring foreign bodies; and scattered through the text are the histories
and cystoscopic pictures of many cases in which marvellously accurate
diagnoses have been made by means of the cystoscope : most of them
having been positively and exactly confirmed by subsequent operative
relief. In one of these cases, a pin was seen sticking in the bladder wall.
The cystoscope was withdrawn, and the foreign body cleverly caught and
removed by a lithotrite. In another, an encysted calculus, which had
qied observation during lithotomy, was most easily discovered by the
visual examination afforded by the electric apparatus, and in yet another
case, the true nature of an obstinate cystitis was by its means discovered
to be due to an ovariotomy suture coming partly through the bladder,
and the patient was quickly relieved of her distress.

But most especially perhaps has the cvstoscope been found useful in
the case of bladder tumors and morbid conditions of its wall, and the
chapter which describes the appearances of disease of this class will be
found to be one of the most interesting and important in the book. The
early diagnosis of malignant trouble has been so positively made out

VOL. 96, NO. 6-DICKMBEB, 1868. 40

612 REVIEWS.

by the author as to lead him to desist from any cutting operation for
purposes of either further diagnosis or relief. It is truly astonishing to
find that so great accuracy has been attained during the brief time
which has elapsed since the introduction of this instrument, and it
would be a rash man who would at this time attempt to prophesy its
limitations. The author concludes the first section of his book with the
statement that cystoscopy *' will become an important atom in the
molecule of the diagnosis and treatment of obscure vesical disease, for
it procures for us a visual examination of the bladder without a cutting
operation. It will, therefore, rank immediately before, and in some
cases supersede the operation of boutonniere, or Sir H. Thompson's
digital exploration of the bladder."

The second division of the volume relates to a description of the
Nitze-Leiter urethroscope, an account of the author's experience with it,
its methods of use, capabilities, and the physiological and pathological
appearances of the urethra, which, by its employment, are brought to
sight. This instrument is also a very valuable perfect and simply work-
ing one, but, of course, its utility will always be superseded by that
of the cystoscopy

Two appendices and a bibliography of recent literature occupy the
balance of the book, and bring to an end one of the most useful and ex-
cellent monographs which have recently made their appearance. In
the first appendix, very appropriately is given the history of the incan-
descent electric lights of Edison and Swan, and in the second are
recorded an additional series of illustrative cases which have been sub-
jected to cystoscopic examination and diagnosis. T. S. K. M.

PROGRESS

o r

MEDICAL SCIENCE.

THERAPEUTICS.

UNDER THE CHARGE OF

FRANCIS H. WILLIAMS, M.D.,

AMI8TAST PBOFEMOB OF MATERIA MEDICA AND THERAPEUTIC* IK HABVABD VHIVEMITT.

Action of Erythrophloein ok the Heart.

This drug has been given by Hermann in various forms of heart dis-
ease, doses of ten drops hourly of cherry-laurel water containing a seventy-
fifth of a grain of erythrophloein to the drachm. ( Oentralblatt fur die ge-
tammte Therapie, October, 1888.)

After one hundred and fifty drops a day of this solution the pulse fell from
100 to 84, and by fifty drops given between noon and five o'clock the pulse
was lowered from 100 to 68. The effect, however, does not seem to be con-
stant nor enduring.

It had a marked diuretic effect in a case of mitral insufficiency and in a
case of fatty heart, but in some cases no special diuresis followed its use. It
caused also enlargement of the pupils in one case, and of one pupil only in
another ; in some other cases it brought on great excitement.

To compare it with strophanti! us, the latter was given in cases in which the
erythrophloein had been without effect on the rhythm or rapidity of the pulse.
The result with strophanthus was in marked contrast to that of the erythro-
phloein, as the heart was made to beat more regularly and slowly, and the
diuresis was prompt and considerable.

This recent drug in its action on the heart is neither constant nor very
great ; it is possible, however, that it may find an application in some cases
as a substitute for digitalis or strophanthus.

The Use <>f Antifebrin in Nervous Diseases.

In the female wards of the insane asylum where Dr. Jacob Fischer acts
as assistant surgeon, antifebrin was used as a nervine for headaches, neural-
gias, in difficulties of menstruation, and also for epilepsy, and as a hypnotic.

Dr. Fischer observed the most satisfactory results in headache and, especi-

614 PROGRESS OF MEDICAL SCIENCE.

ally, in neuralgia, and the result was insufficient only in those cases in which
the headache was dependent upon a pathological change in the brain or
meninges.

The patients took the tasteless and odorless powder gladly after they real-
ized that it gave them great relief. Doses of seven to twenty-two grains were
employed, with no harmful result. Relief was attained in one-quarter to one-
half hour. The patients who, shortly before, were going about in despair
with the pain in the head, felt entirely relieved ; their subjective condition
was good, better than after antipyrin, which generally causes a slight de-
pression.

Fischer believed that the beneficial effect of the antifebrin in headache
was due to diminished blood-pressure, as Cahn, Hepp, and Hare found, since
the blood-pressure called forth by the hypersemia of the brain generally
causes headache.

Fischer also made experiments with antifebrin in epilepsy. The accounts
of other authors in this respect are very contradictory.

Fischer experimented on fifteen patients in his ward, but with only ten
could he carry the test to conclusion. He arranged the experiments in such
a way that in the month of February the patient took no medicine at all, in
the month of March sixty to seventy-five grains of bromide of potassium were
administered, and in the month of April fifteen grains of antifebrin per day,
in two doses of seven and a half grains each, morning and evening were given.
Tt was shown that the antifebrin did not affect the epileptic attacks, either as
regards their number or intensity. The bromide of potassium is also unreli-
able in this disease. Although the attacks are fewer in number and of less
intensity, still they do occur; on the whole, however, antifebrin is the best
means under these circumstances.

Fischer, furthermore, tested antifebrin as a hypnotic, and concludes that it
is a good one in certain cases, but in the greater number of cases it is not
always reliable. Among twenty patients, it acted promptly on only four. In
eight cases it worked only after the first administration ; within the next few
days even large doses were without effect. In another eight cases, princi-
pally of paralysis, it was absolutely ineffectual.

Diuretic Action of the Salts of Mercury.

In the older medical literature calomel is recommended as a diuretic in
dropsy ; in recent text-books this action of the drug has not been clearly set
forth. The study of the diuretic action of the salts of mercury has of late
years been the subject of careful investigation, and among other accounts
there have recently appeared, in the September number of the Deutsche*
Archiv j'iir klinitche MedbAt, two noteworthy articles ; one on this subject by
Dr. Wladyslaw Biqanski, of Poland, the other by Dr. R. Siim/.in<;. who
made clinical observations on the diuretic and hydragogue action of calomel
in the clinique of v. Ziemssen.

Both of these authors used calomel more than the other preparations of
mercury, though they show that the other compounds of this metal are cap-
able of exciting the same action. The best field for the successful adminis-
tration of mercury as a diuretic is in cardiac dropsy, resulting cither from

THERAPEUTICS.

failure of the valves or from primary disease of the heart muscle, except
course, when the cardiac insufficiency is very great, when all drugs would be
less serviceable. It is necessary that the kidneys should be in good condition.

The dropsy resulting from other causes is less apt to be relieved by calomel ;
according to Dr. Stintzing this is true when it is the result of congestion "t"
the portal system, and especially so in chronic parenchymatous nephritis,
though when disease of the heart and chronic nephritis occur together
calomel should be chosen if the nephritis is the less prominent. Dr. Bi-
ganski considers that changes in the kidneys limit or wholly hinder the
diuretic action of mercurial preparations.

Besides acting as a prompt hydragogue, calomel has also a good effect upon
the patient's general condition.

In exudative processes, such as pleuritis and pericarditis, it exercises no
diuretic effect or an insufficient one.

The best rule for its administration is that given by Jendrassik, three
grains, three times a day for at least three days, in special cases longer, up to
twelve days.

The dose of the preparation is of importance : as small doses have no
diuretic action, either medium or large doses are required. The diuresis
begins, according to Dr. Stintzing, on the second to the fourth day after the
administration, seldom on the first or fifth. The polyuria lasts in very success-
ful cases at least three days, generally four or five, seldom up to twelve.
The largest amount of urine obtained in a day was about sixteen and a half
pints, though two to five pints is the usual amount.

It is, of course, necessary to resume this treatment if the dropsy does not
disappear or if it returns.

Digitalis and other diuretics have less effect on the amount of urine than
calomel, though the latter cannot replace digitalis in cardiac diseases ; a com-
bination of both these drugs should prove most serviceable in many cases.

The use of calomel in this way is not free from the effects which are apt to
follow its administration in other diseases. The accompanying symptoms of
salivation, stomatitis, diarrhoea, and colic may be controlled or mitigated by
proper prophylaxis.

If the secretion of the urine is not affected by the calomel, signs of mer-
curialization invariably appear and calomel can only do harm.

Care must be taken to keep the mouth perfectly clean, and suitable gargles
should be used. To correct the diarrhoea, one-sixth of a grain opii puri with
each three grains of calomel is generally sufficient. In case the stomatitis is
marked or the diarrhoea persistent, the administration of the mercury should
be suspended immediately.

Good results may, however, be obtained when the quantity of fluid dis-
charged from the bowels approaches that eliminated through the kidn.
if, however, the extra renal excretion is greater than the renal, the good gen-
eral effect does not occur.

The diuretic action of mercurial compounds depends somewhat upon the
preparation and the method of its application, according to Dr. Biganski, being
most marked after subcutaneous injection, less after internal administration,
and least of all after inunction.

In regard to the theory of this action of the salts of mercury, Dr. Stintzing

616 PROGRESS OF MEDICAL SCIENCE.

believes that they have no direct influence on the heart and bloodvessels, as
he never observed a gain in the pulse as regards volume, tension, or fre-
quency, though often, in consequence of the diminished resistance, the cir-
culation was improved.

The most reasonable hypotheses are those of Jendrassik, who suggests that
the calomel causes absorption of the dropsical fluid by the blood, and of Fiir-
bringer, who thinks that it is due to an irritation of the renal epithelium by
the mercury compound in the blood, and that secretion of the urine is thereby
increased. The latter theory seems the simpler and more in accordance with
all that has been observed. One objection to it, that diuresis was not excited
in normal subjects, no longer holds, since it has been found that a moderate
increase in the urine does occur after the administration of calomel in health.

SUCCINAMIDE OF MERCURY FOR SUBCUTANEOUS INJECTION.

In connection with the diuretic action of mercury, a method for giving it
subcutaneously, to act as a diuretic, or for other purposes may in some cases
be advantageous. The use of succinamide of mercury, which has thus far
been used only in syphilis, was suggested by v. Mering, and it was given to a
number of patients by Dr. Bollert, who employed a subcutaneous syringeful
(one-quarter of a drachm) of a one per cent, solution. It is necessary that
the injection should be made well under the skin but not in the muscular
tissue, and that the needle should be kept clean and carefully disinfected.
No observations were made upon its effect on the secretions. — Therapeutische
MonaUhefte, Sept. 1888.

Antiseptic Solution.

: 20,000).

The following mixture is proposed by

Dr.

Emil Rotter.

To a quart of spring water are added-

Corrosive sublimate .

• tfthgr.(l

Chloride of sodium .

• gr- iv.

Carbolic acid ....

. gr. xxx.

Chloride of zinc,

Sulpho-carbolate of zinc .

a. i gr. lxxv.

Boric acid

. gr. xlv.

Salicylic acid ....

. gr. ix.

Thymol,

Citric acid

aa gr. jss.

This solution remains clear on standing, is odorless and colorless.
These ingredients may be carried in powders and dissolved as required. —
Omtnlbtatt /Or CMntrgie, Oct. 6, 1888.

SULPHONAL.

A report of the use of this hypnotic in the wards of v. Ziemneo is given in

the Cenlr<ilbtatt Jiir l:lini*che M,,li:in of Oct. 6, 1888.

Of twenty-seven cases, 72 per cent, obtained at least six hours' sleep ait or
its use; in 9 per cent, it was incomplete in its action, and in about 19 per

THERAl'KITICS. 617

MBt tli.» result was negative. There were accompanying symptoms in M
per rent., of fatigue, indisposition, ringing in the ears, headache, or vertigo;
vomiting was noticed in one or two cases after its use.

It is slower in its action than chloral hydrate, and its effect is obtained in
one-half to three hours. It has no special influence on the pulse, temperature,
or respiration.

The dose varies from fifteen to thirty grains; as a rule, fifteen grains are
sufficient; though this has to be determined by experiment for each case.

It has the advantage over other hypnotics of less marked odor and taste
and in not affecting profoundly the vital centres.

Camphoric Acid.

As an application to mucous membranes for the treatment of catarrhal in-
flammation, this substance has recently been recommended, by Dr. Max
N i ksel, in the Deutsche med. Wbehenschr. of Oct. 4, 1888.

It is obtained from camphor by oxidizing it with nitric acid ; it is crystal-
line, slightly soluble in water, but readily so in alcohol and ether, and has a
somewhat acid taste. It may be used locally in the form of gargles, spray,
or powder. It is not a poisonous substance, though doses of thirty grains
have caused vomiting, possibly in consequence of local irritation ; in small
doses it is well borne. Combined with bicarbonate of sodium, a solution is
obtained which is more convenient than a solution of the acid in alcohol: an
eleven per cent, solution of alcohol will dissolve only one per cent, of the
acid.

In the treatment of catarrhal affections of the larynx, nares, and bronchi,
as well as in chronic cystitis, it may prove to be a valuable remedy.

Coca ink ix Vaginismus.

In the Brithk Medieal Journal of Oct. 13th, Dr. James Edwards reporte a
case of vaginismus in which a vaginal pessary, containing a grain of cocaine,
was inserted at night and gave complete relief.

Treatment of Lupus.

A case of the successful use of liquor sodii ethylatis reported in the Briti*h
Me" 'I of Oct. 6th, suggests the value of this liquid in certain cases

of lupus.

The application was made daily for three successive days by means of a
small glass tube; two or three days later the patches of lupus were covered
with dry crusts which, on removal, disclosed a perfectly healthy surface.

In using this solution in the treatment of small patches of lupus, it is not
necessary to give an anaesthetic.

Water should not be allowed to touch the part while the solution is being
applied.

[Liquor sodii ethylatis is made by dissolving metallic sodium in cooled
absolute alcohol; it is decomposed if brought in contact with water. — Ed.]

618 PROGRESS OF MEDICAL SCIENCE.

Sterilization of Catgut by Heat.

Reference has already been made to this method of sterilizing catgut, which
was described by Prof. Eeverdin. In the Revue Medicate de la Suisse Ro-
mande, Sept. 24, 1888, he publishes a further account of it, with the result of
the examination of samples of catgut by Dr. V. Bovet, who confirms its
aseptic character. Specimens of catgut were placed in flasks containing pep-
tonized bouillon, glycerin, sugar, etc., which were submitted to different
temperatures; the catgut remained intact and had caused no reaction at the
end of six weeks, while catgut which had been soaked in a disinfectant solu-
tion for twelve days gave a cloudiness to the bouillon in thirty-six hours.

Clinically it is found scarcely to irritate the tissues, and the secretion of
pus is slight. Further, the catgut which has been sterilized in this way is
strong and not too easily absorbed, and thus possesses other desirable
qualities.

MEDICINE.

UNDER THE CHARGE OF

WILLIAM OSLER, M.D., F.R.C.P. Lond.,

PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.
AS8I8TED BY

J. P. Crozer Griffith, M.D., Walter Mendelson, M.D.,

ASSISTANT PHYSICIAN TO THE HOSPITAL Or THE PHY8ICIAN TO THE ROOSEVELT HOSPITAL, OUT-

UNIVERSITY OP PENNSYLVANIA. DOOR DEPARTMENT, NEW YORK.

Local Treatment of Cerebral Meningitis.

Mosler {Deutsch. med. Wochensvhr., 1888, 621) has during several years
employed blisters to the scalp in meningitis with good results. In one very
threatening case of meningitis accompanying acute rheumatism, in which
many other means of treatment had been employed in vain, a cure followed
with suprising promptness the application of a large blister over the shorn
scalp, and two behind the ears. Experiments on animals have convinced him
that, to be effectual, the blisters must be large, and the treatment persisted in.
The author also reported a case of chronic hydrocephalus in which he re-
peatedly performed aspiration, followed by a compressory bandage to the
head. As is usual in such cases, the procedure was not followed by any per-
manently good results, and on one occasion serious symptoms were induced
by it.

Pernicious Anaemia.

Wm. Hunter {Lancet, October 6, 1888, 658) summarizes the results of a
study of the nature of pernicious anaemia as follows: 1. Pernicioai anaemia
is to be regarded as a special disease, hot h clinically and pathologically. 2.
Its essentia! pathological feature is an excessive destruction of blood. 8. The

MEDICINE. 619

most constant anatomical change to be found is the presence of a large excess
of iron in the liver. 4. This condition of the liver M rves at once to distin-
guish pernicious anemia post-mortem from all varieties of symptomatic
anemia, ai also from the anaemia resulting from loss of blood. 5. The blood
destruction characteristic of this form of anaemia differs both in its nature
and its seats from that found in malaria, in paroxysmal hemoglobinuria, and
in other forms of hemoglobinuria. 6. The view can no longer be held that
the occurrence of hemoglobinuria simply depends on the quantity of haemo-
globin set free. 7. On the contrary, the seat of the destruction and the form
assumed by the haemoglobin on being set free are important conditions regu-
lating the presence or absence of hemoglobinuria in any case in which an
excessive disintegration of corpuscles has occurred. 8. In paroxysmal hemo-
globinuria the disintegration of corpuscles occurs in the general circulation,
and is due to a rapid dissolution of the red corpuscles. 9. In pernicious
anemia the seat of disintegration is chiefly the portal circulation, more
especially that portion of it contained within the spleen and the liver, and
the destruction is effected by the action of certain poisonous agents, probably
of a cadaveric nature, absorbed from the intestinal tract.

The Pathology of Recurrent Fevkr.

After comparing the epidemic observed by himself in 1885-6 with those
reported by other writers, Puschkareff (Virchow's Archiv, cxiii. 421) g]
the results of his studies on the pathological anatomy of the disease, made
on the organs of thirty individuals.

By comparison of different specimens it was possible to follow the affection
through all its different stages; a thing not previously accomplished. The
organs examined were the spleen, liver, kidneys, heart, brain, and marrow of
the bones. Considering the microscopic changes in the spleen and liver — the
organs chiefly affected — we find at the height of the fir *t attack a deposition of
lymphoid elements in the Malpighian corpuscles of the spleen, as well u In
foci in its pulp. In the liver there is a moderate dilatation of the intra-
lobular capillaries and a decided parenchymatous change of the endothelium
lining them, together with an accumulation of fat globules. The capillaries
are further filled with red and white blood cells, among which are scattered
large, faintly granular elements, probably coming out of the spleen. There
is also a parenchymatous degeneration of the liver cells.

In the first, npyrcxia there is a retrograde metamorphosis of the lymphoid
elements in the spleen, with the appearance in the pulp of a close network of
thick, shining fibres. In the liver, the cells and the capillaries, with their
endothelium and contents, return gradually to their normal condition.

At the height of the aeetmd attack there is another deposition of lymphoid
elements in other Malpighian bodies and in foci in parts of the pulp not be-
fore affected, continuance of the retrogressive changes in the former foci of
disease, and the appearance in the pulp of large, multinuclcar elements,
especially along the venous sinuses. In the liver there is a fresh and much
more decided dilatation and parenchymatous degeneration of the capillaries.
The large splenic elements appear in the hepatic capillaries in greater
numbers, but very little blood is to be found in them. The endothelium of

620 PROGRESS OF MEDICAL SCIENCE.

the capillaries is less well marked, and fat globules are almost absent. There
is again a parenchymatous degeneration of the liver cells.

In the second apyrexia retrogressive change begins in the new foci in the
spleen and goes on in the old, while the liver as before returns to its normal
condition.

In the third attack fresh spots in the spleen are involved, while the retro-
grade changes proceed in those previously involved, and there is a still more
marked development of the large multinuclear elements in the pulp. In the
liver there is an enormous dilatation of the capillaries; the changes of their
endothelium and contents being similar to those of the second attack, except
that no trace of fat globules is to be found.

In the third apyrexia the spleen behaves as in the second, and the liver
tissues again return to the normal condition.

In general, we see that in recurrent fever there is a parenchymatous degen-
eration of the cells of the organs and of the epithelium of their bloodvessels,
which in the majority of cases does not reach that stage which forbids com-
plete recovery. In some cases, however, permanent alterations remain ; such
as fatty degeneration of the heart muscle, and changes of the connective
tissue in the liver, spleen, and kidneys. The author agrees entirely with
those writers who do not distinguish between bilious typhoid and recurrent
fevers.

Porencephalia.

Audry {Revue de Medccine, Nos. 6 and 7, 1888) has collected from the
literature 100 cases and adds 3 of his own. An exhaustive analysis is
given. Of 90 cases, with full details, the defect was bilateral in 32 ; the
left hemisphere was affected in 38 and the right in 20. In 62 cases the
cavities or spaces communicated with the ventricle. The condition may
result from a variety of causes, acting usually during foetal life ; such as arrest
of development, extreme hydrocephalus, embolism, hemorrhage, encephalitis,
or profound anaemia of the hemispheres.

The symptoms are varied. In 68 cases there was hemiplegia, in some cases
the paralysis was general. This bears out the importance of this condition
in the cerebral palsies of children, as shown above, in the analysis by Osier of
90 autopsies in infantile hemiplegia. Idiocy and imbecility are very common
sequences. Of 57 cases, with full information as to mental condition, 30 were
complete idiots, 12 imbecile, and 15 with fair intelligence.

Dystrophia Muscilauis I'kouukssiya.

Limbeck {FbrttchntUder Med., 1888, 765, from ZeiUehr.f. HeUhtnde, B. ix.)
reports three instances of the disease, of the hereditary typo of Leyden, especi-
ally interesting because a microscopical examination of a portion of excised
made was made in the early stages of the disease. The patients wen two
• is. in whom weakness and atrophy appeared in the flexors of the hip and
extensors of the back. The portion of excised muscle (from the emt<>r
trunci) showed no increase of the perimysium externum or internum, or of
the nui-tcle nuclei. In a few places there was a slight increase of connective
tissue, with a formation of fat, apparently at the expense of the contractile

MEDICINE. 621

substance. The progressive changes in the muscular fibres were much as fol-
lows: there developed suddenly in some spot a rounded swelling, with a dis-
appearance of the striation of the muscle, which took only a diffuse stain
when treated with dyes (Coagulation). This change gradually extended to
the whole fibre, and the sarcolemma could then be seen distinctly outlined
and with nuclei, but filled only with a homogeneous, shining substance,
which could be stained only diffusely, and which exhibited only here and
there evidences of transverse striation.

Ni:iritis Fascia

Kk hhorst (Virchow's Archiv, B. cxii. 237) reports the case of a drunkard
who, six weeks before death, developed paralysis, rapid atrophy, and great
tenderness of the lower extremities and later of the muscles of the arm sup-
plied by the radial nerve. The skin was anaesthetic and the tendon reflexes
abolished. The autopsy revealed no change of the spinal cord, except a few
small recent hemorrhages in the dorsal region. The peripheral nerve trunks
were much atrophied and contained but few healthy fibres, which were
separated by bright, circularly shaped structures, the remains of greatly
atrophied fibres. The endo-, peri-, and epineurium of the nerve-trunks were
unaffected.

The peripheral branches were even more extremely atrophied than the
trunks, and differed from them in that there was a decided increase of the
endo- and peri-neural connective tissue; the thickened connective tissue
lamellae extending between the primitive muscular fibrillar, and in part
surrounding them and producing their atrophy by pressure. On account of
this peculiar condition, which the author has not before seen in alcoholic
neuritis, he applies to the affection the adjective " fascians."

Phexacetix in* Miuraink.

Rabuske (Deutsch. med. Wochenschr., 1888, 37, 767) had under his care a
case of hemicrania in a woman who had been subject to the disease for years.
The attacks occurred every morning and lasted until evening, when they dis-
appeared, attended by chilliness, langour, and paleness of the face. The
headache was so severe that life became a burden. Many forms of treatmen
had been tried in vain, including the use of antipyrine and antifebrin, and
the disease was only growing worse. Finally the writer gave phenacetin in
doses of half a gramme, morning and evening. After six such doses the
attack:-, disappeared without unpleasant symptoms.

Myxcedema.
J. Campbell {Montreal Med. Journ., October, 1888, 256) reports an anomalous
case of myxoedema. There was a swollen appearance; the skin was waxy,
thickened over the whole body, and resilient. Paresthesia was well marked ;
the thyroid gland could not be discovered; there was decided slowness of
intellect; the urine contained no albumen. The case was anomalous in that
there was present a ravenous appetite. There were hungry spells every
two hours, when profuse perspiration would suddenly break out, but would

622 PROGRESS OF MEDICAL SCIENCE.

as suddenly disappear when the patient took nourishment. If she did not
take food when hungry, a sense of weakness came on with trembling and
inability to sit up in bed. She slept soundly, but awakened every two hours ;
if she slept longer than this time she awakened hungry and weak, and with
the trembling mentioned, all of which disappeared after taking nourishment.

The Therapy of Convalescence from the Morphia and Cocaine

Habits.

Under this title Levinstein [Deutseh. med. Wochenschr., 1888, 35, 715)
would describe the treatment of that period beginning with the time when
the symptoms caused by the withdrawal of morphia or cocaine begin to dis-
appear, and lasting long after complete recovery has apparently taking place.
Were more attention given to the patient during this stage of apparent health,
fewer relapses would take place. It is very necessary to impress on the
patient the dreadful consequences of a relapse into the old habits, and in like
manner to teach him that permanent cure must be through the exercise of
his own will. It is a notable fact, too, that when several persons, under
treatment for the morphia habit, are together in an institution for the cure of
these patients, they are very apt to associate with one another, to talk freely
of their affection, and often to combine to deceive the physician in charge.
This association is to be carefully avoided, for there is nothing more ruinous
to the recovery of the lost will-power, than to allow the thoughts of conver-
sation to run on the subject of morphia. The whole therapy of the convales-
cence shortly after the withdrawal of morphia or cocaine may be summed up
in careful oversight of the patient, strict avoidance of alcohol in an institution
for the purpose, and the avoidance of all unpleasant psychic impressions.
While in the institution no friends or relatives should be allowed to stay
with the patient, since they are not under the entire control of the director.
When, however, the patient leaves, after six or eight weeks a desire for occu-
pation should be encouraged under the constant supervision and presence of
a near relative, an intimate friend, or a physician. This supervision should
be both by day and night, and should last at least a year.

Basedow's Disease.

A. Huber (Deutsch. med. Wbcheii.tr/n-., 1888, 36, 729) reports an interesting
case of Basedow's disease in a woman of twenty years of age. After taking
Cold four years before there had developed a peculiar spasm of the left arm
with a tremor and progressive weakness and emaciation of the member, especi-
ally of the hand. Not until after three years did the thyroid gland decidedly
enlarge, and the eye become prominent. Still later, tremor of the legs
appeared. At the time of examination there were struma, exophthalmos,
rapid cardiac action, slight fever, general psychic excitement, left sided hemi-
ami'stlicsiu, and marked atrophy and paralysis in certain muscles of the left
arm. The author omits the discussion of the three cardinal symptoms of the
disease, hut quotes largely the opinions of various writers concerning the
Othi

He helieves that in this case the changes in the left arm and those begin-

MEDICINE. 623

Ding elsewhere were certainly of central origin, probably identical with those
of progressive muscular atrophy. He believes, too, that Basedow's disease
may be of central origin, though its pathogenesis It by no means certain.

Tin: Infi.ikxce of the Vapors of Hydrofluoric Acid on Tcuercle

Bacilli.

In connection with the paper of Gager, reported in The American Jour-
nal of the Medical Sciences for October, 1888, it is well to notice the
results of the experiments of Grancher and Chautard, quoted in the
Ct'ntralbl'itt/i'ir Mnitcke Me'lid/t, 1888, 39, 708. Inhalations of the acid were
given to animals which had received intra-venous injections of tubercle virus ;
but it was found that those treated in this way died as soon as those which
did not receive inhalations. The influence of the acid on the growth of the
bacilli was also tried, and such a strength of the vapor admitted that the
walls of the culture glass were corroded without killing or even entirely
destroying the virulence of the microbes. Still, their virulence was evidently
weakened, for an animal inoculated with the microbes thus treated lived for
two months (and was then killed and found tubercular), while those in
which bacilli had been used, which had not been exposed to the action of the
acid, died in fourteen to seventeen days. The authors conclude, accordingly,
that the idea of killing the bacilli within the human body by the inhalation
of hydrofluoric acid cannot be entertained, but the possibility of weakening,
or perhaps even destroying their virulence, must be admitted.

The Treatment of Phthisis with Calomel.

A. Dochmaxx (Therap. MonaUhef., 415, Sept. 1888), after reviewing the
literature pertaining to the employment of mercury in phthisis, says that in
his experience calomel has a rapidly favorable action in the ordinary forms of
anaemia, even in cases in which iron has been without effect. It increases the
appetite, removes habitual constipation, and regulates menstruation persist-
ently delayed. Then there is a class of cases in which the anaemia is the re-
sult of an already existing phthisical dyscrasia. As is well known, iron in
these cases is entirely without benefit, and even sometimes injures by disturb-
ing digestion. Pulmonary affections, so slight as to be overlooked, often pre-
sent such symptoms, with disturbance of the general nutrition. As the dis-
ease advances a slight fever appears, with a slight dry or mucous cough, and,
finally, objective symptoms become evident. In such cases the treatment
with calomel through two or three months is followed by the best results;
appetite increases, cough and fever diminish or even disappear, and the
night-sweats cease. The author reports in full two cases illustrative of those
treated by this plan; both of them showing the excellent action of calomel
in this disease. In just what way the drug influences phthisis favorably
is not known, nor are we even certain in what way it is rendered soluble
and absorbed into the system. It is superior to other forms of mercury in
that it prevents processes of decomposition in the intestinal canal, without
any injurious action on the digestive ferments. How mercuiy acts on metab-
olism is not understood, but it has been proved by various observers that

624 PROGRESS O*' MEDICAL SCIENCE.

small doses do not at least interfere with it ; it seems probable that it has a
specific action on the tuberculous poison; and its power in hindering inflam-
mation has long been known. The author administers the drug in doses of
about one-fifth of a grain in pills. On the first day the patient takes six
doses of two pills each ; on the second day five doses ; on the third day four
doses, and from the fourth day onward two pills three times a day, through
the whole period of treatment. Every five or six days the administration of
the medicine is stopped for two or three days. With every increase of fever
the dose is raised to twelve or fourteen pills a day. Attention to hygiene
and nourishment is, of course, important, and for the latter purpose the em-
ployment of koumiss is a valuable aid.

G. Martell [Prag. med. Wochenschr., No. 25, 1888) has for three years
been using calomel in tubercular processes, and has learned to consider it
the best specific antiseptic for them, while under proper precautions no un-
pleasant consequences follow its employment. He has had the most favor-
able results with it in tubercular diseases. In the external form it may be
used as a powder applied directly to the parts, while, when the lungs are in-
volved, it may be either internally or topically by inhalation.

Creasote in the Form of Mineral Water in Tuberculosis.

J. Rosenthal [Bcrl. klin. Wochenschr if t, 32, 640, 667, 1888) speaks of the
change in the views of physicians which has occurred in later years, concern-
ing the treatment of the infectious diseases. Either attention is given to the
rendering of the organism resistant against the action of microbes which
have entered it, or antiseptic substances are used which shall directly injure
them, or, at least, render the tissues in which they have settled less fit for their
nourishment and growth. The author reviews some of the various methods
of treatment which have been employed for the cure of phthisis, and shows
what negative results have attended them. There is, indeed, scarcely any
medical substance which has not been tried for it. He believes that, in spite
of these facts, the only manner in which we can hope successfully to combat
the disease is by the way of antisepsis. For this purpose he uses creasote; a
substance not new, and which has been often tried and found of service in
phthisis, but whose administration, in the form in which he gives it, has not
before been recommended. He details at considerable length the opinions
of former writers for and against the value of creasote in phthisis, and relates
theexperiments of Koch, which proved that in a dilution of I in 2000 it pro-
vented the growth of tubercle bacilli on culture media, and in a dilution of 1
in 4000 greatly interfered with it. Basing his opinion on this, Guttmann
claimed that to prevent the growth of tubercle bacilli in the organism, at least
enough creasote must be given that there shall be a dilution of 1 in 4000 of
it in the blood, and that to maintain this quantity there would he required
an amount much too great for therapeutic purposes.

Mthal has made a great number of experiments on thirty-two varieties
of microorganisms, using a one per cent, carbonic-acid-creasote-water in such
a quantity that the culture medium contained 1 in 2000 of creasote. The re-
sults showed that with this strength there was either no growth or but very
slight growth of the microbes. Further experiment proved that creasote in

MKDICINE. 625

weak dilution will not only hinder the growth of the microbes, but will actu-
ally kill them. The objection raised by Guttmann was next met by showing
that sufficient carbonated creosote water could be given hypodermatically to
a rabbit, to make a dilution of 1 in 4000 in its blood, without producing any
disturbance of general nutrition.

The internal administration of creasote in carbonic acid water is especially
to be recommended, because it renders more agreeable a drug unpleasant
to the taste, in the form of mineral water it acts many times more po\\
fully, and carbonated water itself has a favorable action on expectoration
and on digestion. That creasote may have a favorable influence on the
phthisical process, it is necessary that it be administered throughout a long
period of time. Cases in which there is constant or frequent febrile action,
or in which the bacilli in the sputum are very abundant, are less fitted for
treatment with it, but even here it may be of beuefit. It is especially valu-
able when commenced early in the initial apex-catarrh. The good effects of
the creasote water begin to appear in the first few weeks, and consist in in-
^e of appetite, diminution of expectoration, disappearance of cough, of
dyspnoea, and of pain in the breast, and in increase of weight. Those patients
who can visit health resorts should add the use of creasote to their hygienic
treatment. Carbonated creasote water should be prepared of such a strength
that each litre contains 0.6 to 1.2 grammes of creasote and 30 grammes of
cognac. Of this an amount equalling 0.1 gramme creasote should be taken
on the first day, and the dose gradually increased until 0.8 gramme is taken
daily.

Glycerine in Constipation.

Gerstacker {Therap. Monateschr., 425, 1888) speaks of the actual value
which Oidtmann's purgatif possessed, and of the discovery by Anacker that
injections of glycerine had equally good effects. He has himself repeatedly
given glycerine in this way with success, and often in cases in which large
aqueous injections had been unavailing. By attaching a rubber tube one-
half a metre long to the nozzle of the small syringe used for the enema, all
inconvenience is avoided, and the patient can readily use enemata unassisted
while lying on the back. Careful observations were made on fifty-five cases.
In one instance the evacuation of the bowels did not occur for six hours ; the
average time required was eight and a half minutes, and the shortest was two
minutes after the injection. Forty-five times the evacuation was copious;
five times scanty. I'sually the stool was semi-liquid; eleven times hard.
Four times there were repeated evacuations. Careful interrogation of the
patients never revealed the presence of any discomfort in the rectum after
the enema; and only three patients experienced rumbling or pain in the ab-
domen between the injection and the evacuation.

Glomerular Nephriii-.

After reporting some cases of glomerular nephritis with microscopical
studies, and discussing at length the nature of the disease, Obrzut {Rev. <le
MHL, 689, 1888) concludes that in the period of convalescence from scarla-
tina, there is a nephritis localized in the glomerules. It is at least probable,

626 PROGRESS OF MEDICAL SCIENCE.

though difficult to prove, that this is due to microorganisms leaving the
system through the kidneys. His experience has not been sufficiently ex-
tended to allow him to determine whether it develops after other infectious
diseases. It is certainly, however, a very common affection. The first step
in the process is of an inflammatory nature, and consists in hyperemia, and
the migration of leucocytes into the intercapillary interstices, and the forma-
tion of perivascular and intravascular connective tissue. The epithelium
covering the tuft proliferates and desquamates, falling into the cavity of the
capsule, and takes part with the red and white blood cells in the formation
of fibrin (fibrinous glomerular nephritis).

The inflammation of the internal surface of the capsule has no greater im-
port than that of the epithelium covering the tuft, except that the former
may alone constitute a glomerular nephritis and bring about the destruction
of the glomerule. Judging from his own cases, he deems it improbable that
all cases of acute nephritis must necessarily be complicated or preceded by
inflammation of the glomerule. The product of the inflammation of the cap-
sule of Bowman or of the vascular tuft does not differ from that of any other
sort of inflammation ; but consists of a new-formed connective tissue, which
often undergoes hyaline transformation.

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

8URQEON TO THE PHILADELPHIA AND GERMAN HOSPITALS; CLINICAL PROFESSOR Or OENITO-URIXART
SURGERY IN THE UNIVERSITY OF PENNSYLVANIA.

The Treatment of Wounds without Drainage.

Recognizing the desirability of avoiding in all possible ways irritation and
disturbance of wounds, RYDYGIER {Arc/iir fin- klinische C/tirun/ic, Bd. xxxvii.,
1888) has treated forty serious cases without drainage by the following
method :

1st. He selected only such wounds as promised to heal by first intention,
those in which no portion of diseased tissue was left behind.

— < 1 - Thorough disinfection was practised be/ore the operation, during which
irrigation was used very sparingly ; the stitches were applied loosely.

■ ". 1. Several layers of iodoform or sublimate gauze, wrung out of a 1 : 1000
sublimate solution, were laid upon the wound ; over this a loose wad of gauze
or cotton; then layers of dry sublimate gauze and cotton and an antiseptic
l>:ui(lage.

His cases included resections of large joints, arthrectomies, amputations,
■ WhiiiiniiroH'-Mikulicz operation, etc.

In the majority of them he obtained union by first intention. In eight there
was failure to do this, but no serious accident.

SURGERY.

Thk PftOGNOeifl of Carcinoma after Bubgk \i. Interference.

ig (Arrhiv far kHnueke C/iirurgit, Bd. xxxvii., 1888) calls attention to
the fact that the risk to life from operations for the removal of cam
steadily diminishing, owing to progressive improvement of the technique.
The most important question now is, whether we stand in a position through
operative measures to cure carcinoma. Speaking with strict scientific accu-
racy, "cure'' would mean that after a long series of years not only would
there be not the slightest return of the disease at the seat of operation, but
also none elsewhere, as metastatic or glandular carcinoma. Practically, how-
IW, for both the surgeon and patient "temporary '' cure is an important
question. If the latter can be freed from a painful disease two, three, or four
years and his life prolonged for a portion of that time, an important service
is rendered him.

At the Oottingen Clinic, of 66 cases of return of the disease after operations
for cancer of the breast, nearly half recurred during the first six months, and
another third, making 52, during the second six months. Of the remaining 14,
the return occurred in 7 at the end of the second year; in 4 at the end of the
third year: in 2 during the fourth year, and in 1 as late as ten and a half
years.

Of 77 cancers of the rectum, 60 were operated upon by removal of the dis-
1 bowel; 16 with extirpation of the anus and a portion of the rectum;
44 with resection of the rectum but retention of the anus. The peritoneum
was opened 15 times, but in only one case did suppurative peritonitis result.
Much importance was attached to the preliminary preparation of the patient
by diet, emptying the bowels, etc. 18 per cent of the patients remained cured
for more than three years ; 10 per cent, for more than two years. Of 4 patients
upon whom extirpation was practised, 1 had a stricture; not one had conti-
nence of feces. Of 17 operated on by resection 2 had stricture; 9 inconti-
nence; 6 were able to retain the feces. The author thinks these results not
very encouraging, and recommends colotomy as a palliative measure in cases
<>t" n-ctal cancer that cannot be operated upon.

The Abortive Treatment of Syphilis.

Dr. J. William White ( The Medical New*. October 27, 1888) reviews the
subject of the early treatment of syphilis, recommended under the above title
by Mr. Jonathan Hutchinson, and arrives at the following conclusions:

1. While it is unquestionably desirable to begin mercurial treatment at the
earliest proper moment, and while that treatment undoubtedly either sup-
presses or renders milder the subsequent secondary manifestations, and while
there is every reason to believe that in this way the liability to later or ter-
tiary lesions is somewhat lessened, nevertheless, the sum-total of these advan-
tages does not warrant the employment of mercury one moment before the
diagnosis of constitutional disease is absolutely assured.

'1. While in many cases that diagnosis can be made with a high degree of
probability from the appearance of the primary sore alone, yet it cannot be
said that all possibility of error is excluded until some general symptom, such
as the enlargement of distant lymphatic glands, has shown itself.

3. The administration of mercury during the existence of the primary s

YOL. 96, HO. 6 —DECEMBER, 1888. 41

628 PROGRESS OF MEDICAL SCIENCE.

unaccompanied by general symptoms, for the purpose of suppressing or
"aborting" syphilis, is not, therefore, justifiable, unless by confrontation the
diagnosis can be confirmed, or unless there are urgent and unquestionable
reasons for securing rapid cicatrization of the chancre.

4. It is proper to employ cauterization or excision according to the site of
the chancre, in cases in which it is seen very soon after its appearance, and
especially when it is known to have followed intercourse with a syphilitic
person. The chances of preventing constitutional infection in this way, while
very slight, may yet be considered sufficient in such cases to counterbalance
the disadvantages of the method, such as pain, swelling, the production of
phimosis or of suppurating bubo, and the obscuring of the diagnosis by the
resulting inflammatory exudation.

5. Aseptic or antiseptic measures, while harmless, cannot be considered
especially indicated in the local treatment of chancre, and can, in all proba-
bility, have no true abortive influence.

6. The local use of mercurials, hypodermatically or by inunctions, is per-
haps worth a trial, but it is probably inferior to the more radical methods,
based essentially upon the same principles, namely, excision and cauteriza-
tion.

Thoracotomy for Sarcoma of the Chest-wall.

Dr. Roswell Park (Annals qf Surgery, October, 1888) reports an inter-
esting case in which, after amputation of the thigh for sarcoma, the disease
recurred in the chest-wall a little above and to the outer side of the left
nipple. The growth was about the size of a hen's egg, and involved the entire
thickness of the thoracic wall. Operation was decided upon and performed
as follows: The skin over the tumor was separated without any difficulty,
after a crucial incision had been made ; on dissection it at once appeared
that two, if not three, ribs were involved in the mass, and that total excision
would be necessary. To this end, the periosteum was separated on the inner,
side of the last rib involved, at a short distance from the edge of the mass.
The rib proved extremely fragile and broke, a spicule of bone being forced
through the pleura. So soon as the pleural cavity was thus opened, the
opening was rapidly enlarged with a finger, which determined that the growth
was larger on the inner side of the thorax than on the outer ; also, that there
were adhesions in at least one place to the lung beneath. As rapidly as ]>»
Bible the tumor w:is excised with the four ribs which seemed involved, and
which proved to be the fourth, fifth, sixth, and seventh; thus taking out a
portion of the thoracic wall some five inches in length by three and one-half
inehesin width. After removing all of the thoracic attaehments, it was lound
that the band of adhesion connecting it with the lower border of the Dp] er
lobe of the lung was long enough to tie, and alter throwing around it a strong
ligature the mass was easily detached. During ami a In r its removal, a
beautiful demonstration of the action of the heart in its pericardial sac was
afforded. Hasty examination of the left lung, both ocular and by palpation,
revealed numerous nodules scattered through the lung tissue of both lobes
and on their surl'aee. Bad there been a single sarcomatous mass, a portion
of the lung might have been excised.

During all this procedure the patient's respiration was but slightly dia-

SURGERY. 629

turbed, it became more rapid, but the rhythm was not much altered ; his
pulse, however, became quite weak, and stimulants were frequently given
hypodermatieally. He recovered from the shock, however, and lived for a
week. At the autopsy the right lung was found filled with sarcoma:
nodules.

Partial Resection of the Symphysis Pubis in Operations
at the Bladder.

Helferich in throe cases has removed a portion of the symphysis pubis
in order to afford readier access to the bladder. In one case the condition
necessitating the operation was tuberculous caries of the symphysis itself.
In the others it was carcinoma of the bladder, and great enlargement of the
middle lobe of the prostate. Helferich recommends (Archiv fur klinitche
Chirurgie, Bd. xxxvii, 1888) a partial resection as giving sufficient room in
most cases without interfering with the solidity of the pelvis. He makes a
transverse incision and pushes back the soft parts. He pays but little
attention to the periosteum, except that at the lateral portions of the pubis
which are to be retained. He thinks it useless to attempt an osteoplastic
resection of the symphysis, as frequently in the cases in which this opera-
tion is done it will be found impossible to close the bladder wound. After
reaching the bone, he divides it on either side to the necessary depth, per-
pendicularly with a broad sharp chisel ; and then placing the chisel horizon-
tally at the required level and beginning at one of the perpendicular lines, he
divides the symphysis from before backward carrying the chisel from each
end of the exposed bone toward the centre. The upper portion of the sym-
physis thus loosened is easily removed. In the case of caries, complete union
occurred in two months. The case of carcinoma of the bladder showed the
great advantage of this method, giving free access to the tumor which was
upon the upper aspect of the posterior wall, and was excised together with
sound tissue on either side of it. The bladder wound was sewed with catgut
stitches. There was considerable strangury for a few days, but it gradually'
diminished, and healing was complete in three weeks. His case of prostatic
enlargement died eight days after the operation, but was a very unfavorable
one from the beginning — having had retention of urine, urethrorrhagia, etc.,
for some time previously.

He considers the procedure an easy one in all respects and one that can be
completed in a few minutes, but recommends preliminary practice on the
cadaver. The indications for the operation are large malignant tumors, some
forms of prostatic hypertrophy, excessively large stones or encysted stones,
cases of rupture of the bladder, etc.
•

Perineal Lithotrity.

Mi: Reginald Harrison (New York If Journal, October 6, 1888)

calls attention to the statistics furnished by Mr. Donald Day, in a paper on
" Repeated Lithotomy" (British Medical Journal, Feb. 13, 1886), showing
60 cases in 1124 individuals, 30 of the 50 recurrences having been due to
local causes, including undetected stones, stones formed on a fragment left
after the previous operation, and cystitis. These figures included only

(J30 PROGRESS OF MEDICAL SCIENCE.

lithotomy cases, but apply to lithotrity with even greater force. Mr. Harri-
son thinks that if the advantages of litholapaxy could be combined with
those of lithotomy, so far as the latter proceeding relates to the digital
exploration of the bladder, much advantage would follow in cases in which,
from structural complications, a recurrence after lithotrity might almost with
certainty be anticipated. Mr. Harrison does not say what these complica-
tions are, but proceeds to describe "perineal litholapaxy" as meeting the
indications, inasmuch as it would permit of (1) the digital exploration of the
bladder and associated parts, both before and after the removal of the stone ;
(2) the rapid evacuation of the stone; and (3) the drainage and irrigation of
the bladder should this prove necessary. He has operated thus in four cases
of vesical calculus. In three of these the prostate was large, and he was
desirous of draining the bladder after removing the stone ; in two of these
litholapaxy had been previously performed. In the fourth case the stone was
very large.

Catheterization of the Male Ureters.

Axel Wersen reports [Cent, fur Chirurgie, No. 16, 1888) a case of calculous
pyelitis, in which, for the purpose of catheterizing the ureter, he performed
a supra-pubic cystotomy. The examination disclosed a condition of the
kidney on the opposite side from the original disease, which contraindicated
the nephrectomy that would otherwise have been performed. The urine
collected by the catheter showed a profuse epithelial desquamation. He con-
siders the supra-pubic operation as attended with so little danger that it is
justifiable to practise it merely for exploratory purposes.

Antiseptic Internal Urethrotomy.

Mr. W. Bruce Clarke [Lancet, October 13, 1888) has operated on fifteen
cases of stricture of the urethra with the following antiseptic precautions, the
adoption of which, he believes, will remove internal urethrotomy from the
category of dangerous operations: 1. The urethra is rendered as pure as pos-
sible by previous irrigation, and for several days beforehand, both with hot
water and a 1 to 2000 solution of corrosive sublimate. 2. The instrument
which is to be employed should be taken to pieces and carefully scrubbed in
soda and water, and soaked in carbolic acid (1 to 20) for at least ten minutes
before the operation, and only put together at the last moment, just before it
is to be used. 3. When the urethra has been freely divided a full-sized
catheter should be passed into the bladder and retained there for twenty-four
hours. The catheter should be a new one, and should be allowed to soak in
carbolic acid (1 to 100) for at least twelve hours previous, to the operation.
In his series of fifteen cases there was but one rigor, and that was not attended
by any severe constitutional disturbance.

Tin: (in aim i. my of Urethral Stricture by Electricity.

I»k. E. L. Keyes {New York McdicalJou mat, October 6, 1888) reports in
detail the results of his investigation into the alleged remarkable results
obtained by the employment of electricity in stricture of the urethra. He

SURGERY. 631

followed, in his experiments the rules laid down by Dr. Robert Newman,
who has reported two hundred radical cures (!) hy this method. He employed
the insulated urethral conductor of Newman, a constant battery, with a mil-
liamperemeter in the circuit, and controlled this with another joined on the
same circuit. The experiments were conducted with a current of 5 milliam-
peres and below, and the negative pole of the electrode, lubricated with gly-
cerin, ra used. Eight patients, with strictures varying in calibre from fili-
form to 22 millimetres, were treated, one of them by Dr. Newman. In the
latter case Dr. Kcyes found, after about five months' electrical treatment, and
after the patient had been under observation for seven months, that the stricture
was worse by three sizes than before treatment was begun, recontraction to
that extent taking place in less than eleven weeks. In his own test cases he
found that in no instances did any more benefit appear from the electricity
than could have been obtained by ordinary dilatation ; that most positive
failure of cure must be reported for all ; that pain, local inflammation, put-
ting the patient to bed, and threatened perineal abscess must be noted as
among the complications of treatment ; that relapse as to recontraction of the
stricture was found after a moderate interval in all the cases tested, being
most marked, however, in the case of the patient treated by Dr. Newman
himself.

In conclusion, Keyes states that electrolysis with a very mild current — less
than two and a half milliamperes — does no harm ; in fact, does nothing appre-
ciable, and does not interfere with the benefit to be derived from ordinary
dilatation ; a strong current is full of danger, both immediately, from irritating
effect, and ultimately from cicatricial effect, and employment of a negative
pole does not prevent this. It has not been demonstrated that electricity,
however employed, is able radically to remove organic urethral strictures.
The paper is an admirable one in tone and method, and should go far toward
dissipating what was, undoubtedly, a growing professional estimate of the
value of the electrical treatment of stricture, a view which we have always felt
to lie unwarranted and without scientific foundation.

Hernia into the Foramen of Winslow.

Mr. F. Treves reports (Lancet, Oct. 13, 1888) a case in which there were
symptoms of acute intestinal obstruction, with moderate abdominal dis-
tention, but very conspicuous bulging of the anterior abdominal wall in the
epigastric and hypochondriac regions, with dulness on percussion and tender-
ness over the whole epigastric area. Rectal examination revealed nothing.
An exploratory operation was performed on the eighth day by median section.
It was impossible, on account of intestinal distention, to demonstrate the pre-
cise relation of the parts, but a hernia through the foramen of Winslow was
thought to exist. It could not be reduced, and as it was not possible to enlarge
the opening without dividing the hepatic artery, portal vein, and bile duct, the
attempt at relief was abandoned. The patient died in six hours. At the
autopsy it was found that the caecum, the whole of the ascending colon, and
a part of the transverse colon, had passed through the foramen and become
strangulated. The caecum was to the extreme left of the abdominal cavity,
and had forced its way through the anterior layer of the gastro-hepatic

632 PROGRESS OF MEDICAL SCIENCE.

omentum, so that the vermiform appendix was actually lying on the anterior
aspect of the lesser curvature of the stomach, close to the oesophagus.

This hernia is very rare. The foramen is placed above the intestinal area ;
will usually only admit a finger or thumb ; the only portions of the bowel in
close relation fo the foramen are the duodenum, the hepatic flexure of the
large intestine, and the transverse colon, all of which, as a rule, are firmly
fixed. Mr. Treves thinks that such a hernia is only possible when an abnor-
mality of the intestine and its mesentery exists, which represents a reversion
to the condition of intestine met with in the lower animals. The caecum and
ascending colon in this case, together with the jejunum and ileum, were slung
by a common mesentery, the attachment of which to the posterior parietes
was about the duodenal region. There was no mesentery with normal
attachments. Only four similar cases have been recorded; they are quoted by
Mr. Treves.

Railway Spine.

Dr. H. C. Tweedy (Dublin Journal of Medical Science, October, 1888), in a
report on nervous diseases dependent on spinal concussion, summarizes as fol-
lows an address recently given by Dr. Oppenheimer before the Verein J'ilr
innere Medicin :

Certain symptoms are common to all, or at least to the majority of cases of
nervous disease consequent on spinal concussion without external injury.
These symptoms are chiefly psychic, and belong to the affection, mental de-
pression and irritability occupying the foreground. The mental depression is
accompanied by anxiety of mind, the patient's thoughts being always occu-
pied, even in his dreams, with the accident, but is distinguished from pure
melancholia both by the abnormal irritability always present, even in persons
previously remarkable for their phlegmatic indifference to internal excitations,
and by its hypochondriacal character. Severe intellectual disturbance is rare,
but the author has seen a considerable degree of dementia with weakness of
memory, also cases of hallucination, and even of traumatic insanity, requiring
seclusion. Giddiness and cramps, varying between "petit mal" and true
epilepsy, are not infrequent ; but care must be exercised in diagnosticating
such from purely hysterical attacks.

In the domain of the special senses, a mixture of hyperesthesia :ui.l anaes-
thesia, or rather their juxtaposition, is the most frequent characteristic — e. g.,
hyperaesthetic zones are found in the anaesthetic cutaneous areas ; acutenes-
of vision is lowered, while the eye is extremely sensitive to light ; the auditive
faculty is lessened on the whole, while certain sounds react abnormally.
Sensory anaesthesia is a very important subject, and observations have been
made in Westphal's clinic with a view to distinguish genuine from simulated
symptoms. The anaesthesia, e. g., of an extremity, does not usually follow
the course of the nerve implicated, but is spread over neighboring nerves, and
is often overlooked. Typical girdle feeling, and a corresponding an:e>thetic
zone, are rare. Pains are frequent, and usually of the dull kind, especially
headaches. Reflex excitability is more often lessened than increased. The
tendons always react. Motility is almost always affected, the patients move
about slowly, and without energy, the spine is maintained as fixed as possible.

SURGERY. 633

uscular symptoms hinder locomotion. The various ways
of walking are remarkable, and may excite suspicion of simulation. There
is no duubt that the usual signs here do not, as a rule, correspond with those
dependent on "material diseases" of the central nervous system. When one
drags, it is not carried as in hemiplegia. Tremor is frequent, but it
:ubles that of hysteria far more than that of sclerosis. Swaying on closure
of the eyes is very frequent. As to the motor cerebral nerves, the speech

■re most, though there is no trace of aphasia. Speech is irregular
interrupted.

Arthralgia.

M Charles AT/DRY calls attention (Revue de Chirurgie, October 10, 1888)
to a class of cases in which after an old stationary or subsiding arthritis, there
persistent local pains unassociated with any discoverable anatomical
lesif

He details three cases, describing the pain as characterized by its violence,
its long duration, and its obstinacy. It is so severe that the patient
prefers the loss of the limb, and, indeed, amputation was performed in all
three of the cases — one patient dying of shock. Movement is accompanied
by great pain, which is also excited by a mere touch of the skin. The altera-
tions in the affected joints were simply those of old osteo-arthritis. The cause
must be sought in the patient rather than in the disease, although amputa-
tion in two of the cases resulted in permanent cure.

&BBULX8 of Major Amputations Treated Antisepticali.y.

Mr. Frederick Page ( Trans. Northumberland and Durham Medical Society,
February, 1888) reports in tabular form 282 major amputations for injury or
disease, including 10 at the hip-joint and 6 at the shoulder-joint. The opera-
tic >us extended over a period of five years; the total mortality was 4.9 per
cent., and there was but one death from pyaemia. During the previous fuur
years and nine months the mortality was 10.6 per cent., notwithstanding the
fact that there were only 2 hip-joint amputations as against 10 in the latter
period. Mr. Page offers no explanation of this fact, so we may be permitted
to assume that the lessened mortality of recent years is due to improved anti-
septic methods.

koflastic Resection of the Foot.

Dr. Ferdinand H. Gross reports (Medical News, October 27, 1888) an in-
teresting case of the " Wladimiroff-Mikulicz osteoplastic resection," per-
formed by him for caries of the astragalus and os calcis. The usual steps of
the operation are very clearly described. The fixation dressing used by Dr.
Gross was an anterior splint of heavy surgical felting, consisting of leg and
foot pieces riveted to a long iron bar curved over the ankle region in such a
manner as to leave an interval between the pieces of felting at that place.
The limb was swung by means of rings on the anterior splint. The case ran
an aseptic course, and firm union resulted with an admirable artificial pes
equinus, the condition aimed at in these cases.

031 PROGRESS OF MEDICAL SCIENCE.

The Aseptic Use of Malgaigne's Hooks in Transverse Fracture

of the Patella.

Dr. J. William White reports {Medical Record, October 27, 1888) a case
of recent fracture of the patella treated by aspiration of the joint and the
use of Malgaigne's hooks, applied during antiseptic irrigation, and enveloped
in antiseptic dressings. The case ran an apyretic course, entirely without
complication, and at the end of five weeks there was apparently good union,
the line of fracture being barely discoverable. The dressings were removed
and passive motion begun. This was followed at the end of another week by
a separation of the fragments to the extent of three-eighths of an inch.
The usefulness of the limb was but very slightly impaired. Dr. White re-
views the general subject of the treatment of the fracture, and summarizes
his views as follows : 1. The results obtained in transverse fracture of the
patella by means of splints, plaster dressings, or bandages are extremely un-
satisfactory owing chiefly to the absence of bony union, to the length of the
fibrous band interposed between the fragments, and to the accompanying
atrophy of the quadriceps muscle. 2. If further observation shows that the
chief difficulty in getting good union lies in the separation of the fragments
and the presence of blood and synovia, the treatment to be preferred will
probably be some form of the prepatellar wire suture or the aseptic use of
Malgaigne's hooks after aspiration of the joint. 3. If, however, as seems
highly probable, the chief cause of non-union is found to be the presence be-
tween the fragments of portions of the aponeurotic tissue in front of the
joint, it will be good surgery in all cases of recent fracture to cut down with
the strictest and fullest antiseptic precautions and wire the fragments. 4. In
old fractures, on account of the increased risk and the difficulty of the opera-
tion, the disability of the patient should be quite decided before wiring is
recommended by the surgeon.

Irreducible Luxations of the Shoulder.

M. Charles Nelaton considers at length (An/tin* QfyitrcUea de MMecme,
October, 1888) the causes of irreducibility of old luxation of the shoulder,
and arrives at the following conclusions: 1. That the principal obstacle in
the reduction of old luxations of the shoulders is the retraction of the dis-
used capsule. 2. That this lctnutimi presents two phases: the first, during
which the lips of the capsular opening tightly encircle the head of the bone,
and in that way prevent its return to the glenoid cavity, which is free and
ready to receive it; the second in which the head cannot again enter the
glenoid cavity, not only because it is thus held by the edges of the capsular
rent which permitted its escape, but also because the articular cavity lias be-
come too small to receive it, owing to the narrowing anil atrophy of the
capsule. 3. That these two causes of irreducibility indicate two different
ineiliotls of treatment: the first being amenable to traction and passive
movement ; the second requiring operative interference.

Polaillon has recommended an extensive subcutaneous tenotomy in such
cases, followed after a few days, which permit of the healing of the cuta-
neous wound, by attempts at reduction during anaesthesia. He and M.

OTOLOGY. 635

Mollk're have had successes by this method, but M. N61aton objects to it be-
cause this section in the dark may leave the strangulation of the head by
the lips of the capsule unrelieved, because as fracture frequently accompanies
these luxations small bony fragments may interfere with the action of the
tenotomy ; and because the method requires two successive operations. He
recommends in his second class of cases, in which the capsule has narrowed,
an incision similar to that used by his father in cases of resection of the
shoulder, beginning at a point midway between the coracoid and the ant<
angle of the acromion, and about eight centimetres in length. The deltoid
and the supra- and infra-spinatus, and teres minor are divided, and the
capsule opened. If there are anterior adhesions to the head of the acromion,
these are separated by a curved elevator, and the head is replaced in the
glenoid cavity. The capsule, tendons, and deltoid are then reunited by catgut
sutures.

M. And. Castex details (Revue de Chirurgie, October 10, 1888) six cases of
reduction of old luxations of shoulder by means of a method which con-
essentially in using the semiflexed forearm as a lever, and causing the head
of the humerus to execute the movements of external and internal rotation,
flexion and extension, abduction, adduction, and circumduction. In this
way he claims that in the majority of cases all adhesions may be broken up,
the various forms of violent traction by pulleys, etc., may be dispensed with,
and the head of the bone replaced more certainly and more safely. If a first
attempt fails, he recommends making the second, after an interval of three
days, the consecutive inflammation producing softening of the adhesions.

OTOLOGY.

UNDER THE CHARGE OF

CHARLES H. BURNETT, M.D.,

PkorxasoR or otologt in the Philadelphia poltcusic axd college ro« geadiati* is medicihe, etc.

Coxsecltiyk Otitic and Facial Paralyses II ■ e op a

Revolver Shot in the E.\ih:.\ai, Meatto.

Ladisi.ai < Farkas, of Buda-Pest (Anhivf. Ohrmheilk., Bd. 27, 1888), gives
an account of a man, forty-three years old, who, with suicidal intent, .-hot
himself in the right ear with a revolver. Immediately there ensued facial
paralysis on the right side, and a copious sero-purulent discharge set in from
the right ear, but the latter gradually diminished. Besides, the patient com-
plained of a dull, hissing sound in his ear, vertigo upon turning his head,
and hemicrania on the right side. Taste and smell were unaltered. Three
weeks after the injury, the patient suffered from a pharyngeal abscess, after
the rupture of which it was supposed the bullet escaped, as when first seen
and operated upon, over fifteen months after the injury, only a few pieces of

636 PROGRESS OF MEDICAL SCIENCE.

necrotic bone and small crumbs of lead were removed. In a few days, under
iodoform dressings the wound healed. Some years later the patient was found
to be entirely well. It is of interest to note that in this case the facial nerve,
under pressure by pieces of necrotic bone, for fifteen months, resumed its
functions as soon as this pressure was removed. The headache and the ver-
tigo, with all unsteadiness of gait, disappeared after the operation.

Impeded Nasal Respiration and Purulent Otitis Media.

Dr. A. Bartii {Berlin. Min. Woclien&ehr., 1888, No. 2; Archivf. Ohrenheil-
kunde, Bd. 27, August, 1888) demonstrates that sometimes impeded nasal
respiration can induce either an acute or a chronic purulent inflammation
of the middle car. Thus, the swelling induced in the nares by a galvano-
cauterization has induced an inflammation in the ear; on the other hand, a
chronic otorrhcea will often rapidly disappear after the chronically stopped
nose is made free.

The subject, while not new, is of great importance, and should be kept in
mind in the present era of heroic nasal treatment by the galvano-cautery.

Reflex Epilepsy from Ear Disease.

Emil Pins, of Vienna {International Clinical Observer, 1888, No. 23, and
Archivf, Ohrenheilkunde, Bd. 27, 1888), contributes an article of interest on
the relation of the organ of hearing to epilepsy, and refers to a case of reflex
epilepsy given by Boucheron (Bulletin Medical, No. 75, 1887), in which severe
epileptic attacks were checked by the cure of a catarrh of the Eustachian
tube and middle ear. There are mentioned cases of transitory epilepsy, which
occur with marked cerebral symptoms, in consequence of purulent catarrh
of the middle ear, and caries of the petrous bone, which the author refers to
an affection of the central organ, since he explains them like Jacksonian
epilepsy, viz., as originating in either a lesion of the brain or its meninges.
I Ic then cites a case of epilepsy excited reflexively from ear disease, observed
in a young, hysterical woman, who had, a polypus in the left ear, and who
became extremely pale, nauseated, dizzy, and suffered from palpitation of
the heart whenever the polyp in the ear was touched with a probe, so that all
examination and treatment had to be stopped. Finally, the patient cam* one
day with her mind made up to endure everything, and have the polypus
removed. The polyp was then examined with a probe, and removed with
the Wilde's snare without interruption. Scarcely was the operation finished
before the patient uttered a loud cry, fell senseless to the floor, foamed at the
mouth, manifested heavy convulsions of the entire body, and in a few minutes
fell into a profound sleep. Upon waking, she vomited several times, and
OOald recall nothing of what she had gone through. The patient had never
before suffered from an epileptic attack, and has not had another, nor is there
any hereditary neuropathic weakness.

The writer finally urge* the necessity of bestowing more attention to the
organs of hearing in epileptics than has heretofore been the case — possibly to
tin- injury of the patients. I For just as the sexual organs, old wounds, etc.,
have been examined for the causes of epilepsy, so should the organ-
hearing not be disregarded!!! this connection.

OTOLOGY. 637

in riu: Lett Temporal Lobe without Disturbam

Hkarixg axd Sri

H. Senator, of Berlin (Charile Ann., vol. xiii., 1888; Archiv f. Ohrenheif-
kutide, Bd. 27, 1888), observed in a post-mortem examination of a man who
had died of suppurative hepatitis and consecutive peritonitis, a small abscess
the rise <>f a walnut, filled with thick, yellow, odorless pus, in the left temporal
lobe. It was placet! so deep that the cortical substance was untouched by it.
The abscess possessed several irregular offshoots which extended above and
below in the temporal convolutions, and nearly reached the cortical substance,
but the parts thus touched appeared only slightly reddened. A second, small
abscess, the size of a pea, was found in the semi-oval centre of Vieussens ;
otherwise the brain was free from disease. The abscess in the temporal lobe
was in that part of the brain the destruction of which is usually followed by
sensory aphasia (Wernicke) or word-deafness (Kussmaul), but in this case
had not betrayed its existence by such symptoms. During his illness the
patient had complained of only intense tinnitus in the left ear, but examina-
tion of the ear revealed nothing abnormal.

.Viral Reflexes, and ax Otospixal Reflex Cextre ix the
Cervical Medulla.

:.e contributes an elaborate paper on the above-named topic; and gives
an account of his apparatus and experiments whereby he arrives at the
following conclusions :

1. In binaural audition, the movements of accommodation, *'. «., the mus-
cular action of the motors in the transmitting apparatus of the middle ear,
are simultaneously and similarly set in action.

2. By the forces acting upon one ear, similar impression is made on the
other; for an experimentally produced movement in one ear provokes a
similar active reflex in the other ear:

3. E. g., if a vibrating tuning fork is held in front of the free ear, while air
is compressed by means of an air bag arranged for the experiment connected
with the opposite ear, the subject perceives a diminished sound of the fork due
to the tension in its conducting parts which has been evoked reflexively,
thus proving the existence of binaural reflexes.

4. This method of examination demonstrates the mobility of the stapes,
the activity of the motors, and their alterations : it is therefore an important
addition to aural semeiology.

•">. When the ears are healthy and the hearing normal in both, the synergetic
effect on the accommodation of the ear disconnected with the apparatus of
experiment, may be wanting, the cause in such cases is extra-aural ; it is, in
fact, the reflex centre in this instance which fails to unite the two organs
and associate their movements.

6. Clinical experience shows that the disappearance of the aural reflex in
such cases coincides with lesions in the cervical cord (five times in seven).

7. Clinically we may assume from the presence or the absence ot these
binaural reflexes, the presence or absence of lesions in the cervical cord ; their
disappearance renders diagnosis clear.

638 PROGRESS OF MEDICAL SCIENCE.

8. These reflexes do not appear to have any connection with pupillary re-
flexes ; they remain when the aural have ceased, and vice versa. Nevertheless
it seems shown by the facts that binaural reflexes are more easily influenced
by hypertrophic cervical pachymeningitis.

9. Investigation of reflexes of binaural accommodation is related to the
study of affections of the medulla.

10. The centre of reflex movements of binaural accommodation is situated
in the cervical medulla, as seen by its abolition in the course of maladies of
this part of the spinal cord.

DISEASES OP THE LARYNX AND CONTIGUOUS

STRUCTURES.

UNDER THE CHARGE OF

J. SOLTS-COHEN, M.D.,

or Philadelphia.

CESOPHAGOTOMY FOR FOREIGN BODY IN THE LARYNX.

A case of oesophagotomy is reported (Albany Med. Annals, October, 1888),
performed three days after a shawl-pin had been swallowed, but with failure to
find the foreign body. The bristle probang had been tried ineffectually before-
hand. Twenty-one days after the operation, during a violent fit of coughing, a
shawl-pin two and one-quarter inches long, with a head of black jet one-half
inch in diameter and one-fourth inch thick, was expectorated from within
the larynx where it had been lodged. It is but fair to state that on physical
exploration of the oesophagus, obstruction had been encountered at about its
middle third, which had caused considerable difficulty in freeing the olive-
shaped tip of the sound. We miss, however, any reference to laryngoscopic
inspection despite the mention of a troublesome cough commencing shortly
after the accident, and which gave great pain both before and after oesopha-
gotomy, and which apparently continued until after the expectoration of the
foreign body. Surely such a large body as this pin would have been readily
detected in the larynx ; and such detection, before subjection to oesophagotomy,
would have spared the patient a useless operation.

Nasal Aprosexia.

Under the title aprosexia, Prof. Guye, of Amsterdam, groups (DetiMi.
med. II or A., 1887, No. 43; Oct. 4, 1888, No. 40), a series of cases of disturbance
of intellection due to intranasal disease, the chief symptom of which is in-
ability to fix the attention upon a specified subject. The other symptoms are
marked forgitfulness and headache. The headache may be a continuous or
an intermittent sensation of pressure, or it may be an intense hemicrnnia
occurring in the mornings especially. Its pathogenesis is referred to the
connection described by Key and Retzius between the subdural lymph spares

LARYNGOLOGY. 889

of the brain and the lymph vessels of the nasal mucous membrane; as well as
t-> the occasional interruption to the loss of \vat«r through the nasal mucous
membrane when the passages are more or less obstructed. Aprosexia is,
tlu- re fore, regarded as a retentive process hindering the elimination of the
products of tissue-changes. In addition there are vaso-motor disturbances due
he disturbances of nutrition of the nasal mucous membrane. The cases
which seem to indicate this are those in which, during the attack, a circum-
•ed congestion of the skin is perceptible, especially at the root of the nose.
(Juye distinguishes three forms of aprosexia, physiological, neurasthenic, and
nasal, with various intercomplications and combinations. Four cases of nasal
aprosexia are narrated in detail, the patients being males between fourteen
and twenty-six years of age. By topical treatment of the various morbid
intranasal conditions present, cures were effected.

The Comparative Merits of Tracheotomy and of Intubation
ix the Treatment of Croup.

At the meeting of the American Surgical Association, September 20, 1888,
Dr. Geor< ;e W. Gay discussed this subject (Boston Med. and Surg. Journ., Oct.
11, 1888) in a very thorough manner, for due consideration of which we must
refer to the original paper. While fully appreciating all that intubation has
done and may do in croup, he does not believe that either procedure can sup-
plant the other in their respective spheres. He recognizes that, while the
proportions of recoveries are about the same, the proportional recoveries at
an early age, say under two years, are much larger in intubation.

Laryngectomy.

Dr. Vixcexzo Omboni reports (Annali universale di Med. e Chir. Milano,
-to, 1888) a case of extirpation of the larynx with the first ring of the
trachea, and a portion of the pharynx and oesophagus for epithelioma. The
patient was a male, forty-six years of age; the operation was performed June
L'^th, and death ensued August 8th. The case, and the operative steps, are
reported in minute detail, and the report is followed by some general con-
siderations on the operative procedure.

Fetiu Demccative Tracheit:

Under the name tracheal ozama Luc details (Arch. Lar. d Ri>-.f Feb. 15,
1888) three cases of fetid tracheitis following fetid ozsena in two females and
one male. Viscid crusts adhered to the walls of the trachea which, when ex-
pectorated on rising in the morning, were analogous in odor, in color, in con-
sistence, and in microorganisms with the crusts of ozipna.

Paralysis.

Vilato (Got. Med. Catalana, March 15, 1888; Rev. Men. de Lar., October,
1883) reports a case of dysphonia, paralysis of the right half of the palate, of
the tongue, of the larynx, and of the upper and lower limbs, in a girl seven
years of age. The diagnosis was general paralysis following diphtheria.

640 PROGRESS OF MEDICAL SCIENCE.

Radical cure was obtained by several seances of hypnotism. Lacoavret justly
attributes the paralysis to hysteria.

Phlegmonous Sore Thkoat.

Hager (Berlin, klin. Woch., No. 12, 1888; Rev. Men. et Lar., etc., October,
1888) reports a case of recovery after more than a months' illness. There was
a sudden angina with delirium, and without perceptible cause. The inflam-
mation extended to the oesophagus, stomach, pericesophageal tissue, and the
larynx, the engagement in the latter being so severe as to render prospective
tracheotomy imminent for a short period. There was then a general septi-
caemia from resorption of the pus formed in the pericesophageal connective
tissue.

The longest survival in Senator's group of cases was sixteen days.

A Case of Congenital Membranous Occlusion of the Larynx
Requiring Section of the Thyroid Cartilage.

Occlusion of the larynx by a web of membrane between the vocal bands is
usually remediable by intralaryngeal surgical procedure. An exceptional in-
stance, in which unusually severe measures were required, is reported by Drs.
Seifert and Hoffa (Berlin, klin. Woch., March 5, 1888). A congenital
web in a female sixteen years of age was so tough that the point of a knife
became broken off in an attempt to incise it intralaryngeally. It also resisted
attempted division with an electric cautery. External access was then de-
cided upon. After incision of the skin, an enlarged thyroid gland was de-
tached by dividing the fascia after Bose's method, and then pushed downward.
High tracheotomy was performed, and Trendelenberg's canula inserted, and
then the crico-thyroid membrane was divided horizontally. A probe-pointed
knife was pushed up and behind the web, which was then divided from be-
hind forward, and the thyroid cartilage was divided in the middle line at the
same time. On separating the wings of the cartilage, the occluding tissue was
found to be membranous only in its posterior portion. Anteriorly it formed a
curtain which passed obliquely forward, and which was adherent to the anterior
wall of the larynx about a finger's breadth below the vocal bands. This was
resected so as to free the lower portion of the larynx, and restore the vocal
bands nearly to their normal configuration. Cartilage, pericardium, muscu-
lature, and skin were secured in position with catgut sutures. An ordinary
canula was retained in the trachea until the fourth day. On the twelfth day
cicatrization was complete. Two weeks later, the anterior third of the vocal
bands had become readherent. This was overcome by systematic dilatation
with Schrcetter'8 bougies; but continuous dilatation was still necessary,
although the voice had become good; a constant disposition remaining to ra
adhesion at the anterior commissure.

Cocaine in Epistaxis after Sneezing.

Dr. Ziem (Dent. med. Woch., October 4, 1888) reports a case of severe
bleeding from sneezing after removal of an intranasal growth, in which tam-
pons failed to arrest it, and were hlown out in the paroxysms. A tanipon

LARYNGOLOGY. 641

saturated with a ten per cent, solution of cocaine arrested both the bleeding
and tin- Knotting.

| amphoric Acid in Catarrhal Inflammations.

Dr. Max tflKSSKL (Dent. med. Woch., October 4, 1888) confirms the ofaoi r-
vations of Reichert and of Fiirbringer in the usefulness of camphoric acid in
catarrhs of the mucous membranes. He has used it internally and topically
by pencilling, by gargles, by spray, and by inhalation. Lozenges containing
from one to two grammes of the crystals of camphoric acid at night had a
good influence on the night-sweats of phthisis. Solutions were made with a
five per cent, solution of bicarbonate of sodium added until the acid dissolved
and evolution of carbonic acid gas ceased, the proportion of the alkali to the
acid being about three to four. This was found useful in mild laryngeal and
nasal catarrhs, after daily pencillings for eight to fourteen days. In the
severer cases and in tuberculous cases no benefit had been observed apart from
improved subjective feelings.

Inhalations in phthisis and in chronic bronchitis with a one per cent, alka-
line solution were more favorable. The irritation was lessened, and the ex-
pectorations were facilitated in nearly all the patients. Much could not yet
be said of the value of gargles; a more prolonged observation being necessary.

A Tracheal Canula for Patients with Goitre.

Dr. Fritz Salzer describes and illustrates ( Wien. klin. Woch., October 18,
1888) a comfortable canula for patients with goitre, who often have reason to
complain of the pressure produced by the ordinary canula. In the absence
of a canula especially constructed for the purpose, he has used with entire
satisfaction an extemporaneous contrivance made as follows : A hard-rubber
tube, of proper calibre and fifteen and a half centimetres in length, is bent
nearly rectangularly at a distance of five centimetres from one extremity.
This bent portion is intended for the trachea, and the horizontal arm for the
track through the tissues in front of it. The superior surface of this hori-
zontal arm is to be pierced horizontally with a series of pairs of small holes
eight millimetres apart. An ordinary canula plate is passed over the outer
extremity of the canula, and is held in place with a safety-pin passed through
one of the pairs of perforations, at any point that may be desired, and thus its
position is readily changed from time to time as tumefaction may require.
The shape of the canula is similar to that of the outer canula of Mr. Durham,
and the perforations and safety-pins are substituted for the movable collar
carrying the plate.

A Case of Satisfactory Phonation without the Aid op ah
Appliance after Laryngectomy.

Dr. Hans Schmid reports (Deutsche med. Woch., October 18, 1888) a case
of a man upon whom laryngectomy, including removal of the epigl<>
performed for carcinoma of the larynx by Dr. Ziegel, October 28, 1886. Some
doubt is expressed as to the accuracy of the diagnosis, but that is not the
point in question. In the spring of 1888, the patient, exhibited August 4th

64:2 PROGRESS OF MEDICAL SCIENCE.

to the Greifawcdder medicinkcher Verein, presented himself to Dr. Schmid,
who had attended him a year previously, with a loud and distinct, though
monotonous, voice. On examination the muscles of the cheek were found to
have undergone great development ; the dorsum of the tongue was very high
in the mouth ; the tonsils large and projecting ; the palatine folds large, pro-
jecting, and lustrous. These structures seem to have acquired the power to
become so pressed together as to form a sort of adventitious glottis. Dr.
Schmid raises the question whether the unexpected and apparently fortuitous
results in this case may not be an indication for awaiting the results of nature
after laryngectomy, in preference to the early use of a reeded canula or arti-
ficial substitute for the phonal portion of the larynx. We are compelled to
forego a number of interesting details.

ECCHONDROSES OF THE SEPTUM NARIUM AND THEIR REMOVAL.

Carl Seiler {Medical Record, February 18, 1888) refers simply to those ex-
crescences on the surface of the cartilaginous plate, and to which he attributes
an important rdle in the production of the symptoms of nasal catarrh. He
has witnessed their development upon the perfectly normal septum in conse-
quence of pressure upon them of turgescent tissue over the anterior extremity
of the lower turbinated bone, and he has seen a resultant tendency of the
nose to bend over to the opposite side. He has seen them result from irrita-
tion of the finger-nail from scratching the septum in picking off crusts. He,
therefore, concludes that these simple cartilaginous excrescences are due to
local irritation of the cartilaginous septum primarily, and of the perichon-
drium secondarily. This result he believes to be favored by the peculiar
histological structure of the hyaline cartilage, to which the blood is supplied
by loops of vessels dipping into its substance from the perichondrium ; and
by the cell nutrition being carried on by osmosis from one to the other
without the intervention of a capillary network of bloodvessels. Hence,
localized increase of blood supply to these loops must necessarily give rise to
a more rapid cell division and proliferation of the intervening cartilage cells
than is demanded to supply the waste by cell death, and thus localized in-
crease of cartilage tissue must result therefrom. Dr. Seiler finds that when
these cartilaginous excrescences have existed for some time they are apt to
become ossified or calcified in the centre.

These ecchondroses require operative removal, but previous thereto the ex-
isting hyperemia of the mucous membrane must be reduced to lessen the
shock from the operation, and to facilitate the healing of the wound. The
operative procedure is preceded by the application of a four per cent
solution of cocaine on cotton maintained in contact for about ten minutes.
A fine cambric needle is then inserted to ascertain whether sensibility has
been destroyed, and to determine the presence or absence of ossification in the
excrescence. The excrescence, if cartilaginous, is then removed with a
slightly curved double-edged knife applied from below upward for about half
the extent of the excrescence, and then from above downward. Any hard
centre is cut through by tapping the handle of a chisel applied to that portion.
1 1 t he excrescence is an ossified one, a grooved director is passed beneath it, and
the dull point of a plough-shaped knife is pushed along the groove, much in

KMATOLOGY. 648

ne way in which a wood-carver uses a similar tool. As soon M the
progress of the knife is obstructed, a gouge with a slanting edge is substituted
and driven forward with a few blows from a mallet. When the hard

an cut through, a pair of bent scissors is employed to sever any portion
of mucous membrane remaining attached abave.

DERMATOLOGY.

IXPER THE CHARGE OF

LOUIS A. DUHRING, M.D.,

professor or dermatology in thr i-nitcr-sity or Pennsylvania;
AXD

HEN It Y W. STELWAGON, M.D.,

PHYSICIAN TO THE PHILADELPHIA DISPENSARY FOR SKIN DISEASE*.

REATMEXT OF LlCHEX RlBER PLAXl F&

In the Berliner klinische Wochenschri/t of September 10,1888. IIerxheimek
reports several cases of lichen planus in which good results were obtained
by the local application of chrysarobin. The author, while admitting tin-
favorable effects from the use of Unna's salve of corrosive sublimate and
carbolic acid, states that in his experience its use has occasionally given rise
to an eczema. The chrysarobin is applied either as a paint in the gutta-
percha solution, ten per cent, strength, or in the form of an ointment, the
former being the preferable method. The solution is painted over the affected
areas twice weekly. The unguent is naturally more positive in its action,
but not so much so as to compensate for its disadvantages ; it is to be recom-
mended, therefore, only in the most obstinate cases, or those in which a rapid
result is especially desirable.

Dermatological Notes: Acute Multiple Bymmbt&igal GrAVOBi
Bullous Eruption due to Quixia.

A case of the former and a case of the latter are reported {Journal of Cuta-
neous and Genito-ur'nmry Diseases, September, 1888) by Elliott. In the
case of acute multiple symmetrical gangrene, the first symptoms were noted
a few days after prolonged fatiguing work, and consisted of three or four pin-
head to pea-sized, painless, circular, dry, grayish-black lesions, defined by a
slightly elevated, red border, and seated on each buttock immediately over the
acetabula. For several days new spots continued to appear symmetrically
on both buttocks, and some increase in size was noted in the earlier lesions.
There were no subjective symptoms, but around the larger spots for a variable
distance complete anaesthesia was noted. The destruction of tissue in the
most conspicuous lesions extended to the subcutaneous connective tissue.

▼OL. 96, NO 6.— DECEMBER, 1888. 42

644 PROGRESS OF MEDICAL SCIENCE.

Pressure upon the lowest spinal region produced considerable pain. The case
was treated on general principles, recovery being complete in three or four
weeks. The patient's general condition had remained throughout satis-
factory.

In the case of the bullous eruption from quinia, it was noted to follow
a five grain dose, and the same phenomena had presented from the same
cause on two different occasions. The cutaneous symptoms occurred an hour
after the drug had been taken, consisting for the most part of variously sized
blebs seated upon the hands, wrists, feet, lips, tongue, and roof of the mouth.
The trunk remained free. The eruption retrogressed rapidly.

The Kreuznach Mother-liquor and Calcium Chloride in the
Treatment of Skin Diseases.

In the Centralblatt fur die Gesammte Therapie for July, 1888, LlER gives
his experience with the use of the Kreuznach mother-liquor in the external
treatment of various cutaneous diseases. Its efficacy, according to this
writer, depends upon the calcium chloride it contains ; this latter used in the
same way giving similar results. Two effects may be produced by these
applications, a primary or superficial, and a secondary or deep. The former,
which is especially adapted to the treatment of moist eczema, impetiginous
eruptions, erythema, and psoriasis, is obtained by cool baths of short dura-
tion, and the application of a paste, consisting of terra silic and zinc oxide,
aa ^iss; vaseline, ^v; and mother-liquor, £viij. The bath is not to exceed
a temperature of 90°, and may be with or without the addition of the mother-
liquor. For the deeper effects, baths of the temperature of from 93° to 99°,
containing a large quantity of the mother-liquor and of longer duration, and
also by the use of compresses of the same, pure or diluted ; this form of
treatment is more especially useful in all forms of cutaneous disease in which
infiltration or induration is a prominent feature.

Lactic Acid in Tuberculous Ulceration and Lupus.

Rafin records (Lyon Med., July 8, 1888) several cases of tuberculous
ulceration and lupus in which lactic acid was employed with favorable
results. In the two cases of tuberculous ulcer of the tongue, and in two
cases of lupus involving portions of the face, its action, while slow, was con-
tinuous; complete cure resulting in the former cases insixweoks; in the
latter, in several months. It was employed in eighty per cent, strength.

Horny Growth on the Dorsum of the Hanp.

Ellison reports {Lancet, Sept. 15, 1888) an interesting case of cornu cuta-
neum. The growth was of horny consistence, measuring at the widest part
of its base an inch and a half in diameter, and at its free end about th
fourths of an inch. It was somewhat curved and three inches in length. It
was freely movable with the integument, and was seated over the tendons of
the extensor communis digitorum close to the metacarpophalangeal joints
of the fore, middle, and ring fingers of the right hand. The growth had its
origin in a wart.

DERMATOLOGY. 645

Bktesjs Eruption of Bilatekal Herpes Ophthai.m:

Under this head a case is reported (Lancet, July 7, 1888) occurring in the
course of chronic pneumonia with diffuse interstitial nephritis, by Robertson*.
While under observation for the latter disease, a herpetic eruption appeared,
ushered in quietly, and without pain or much itching. The vesicles appeared
in a thickly set patch under each eye, extending to the external canthu9, and
internally well up the bridge of the nose on each side; around the palpebral
margins, amongst the cilia, and thickly set on each eyebrow; several on each
frontal region ; several vesicles behind each ear; three on the right helix and
over the upper lip ; one on the nose over the bridge, and one on the right side
of the tip of the nose. There was soon associated with the eruption con-
siderable cutaneous disturbance, with swelling of the eyelids to absolute clo-
sure. The eruption was characterized by the usual multiformity of the
herpetic lesion — here vesicular, there bullous, and again pustular, all present
simultaneously. The eruption under the lower lids and on the eyebrows broke
down on the third day with the formation of foul ulcers discharging freely.
Throughout the attack no ocular symptoms of any gravity appeared. The
conjunctivae became suffused slightly. The attack lasted three weeks.

A Case of Urticaria Pigmentosa.

Mibelli contributes (Monaithefle fur praktische Dermatologie. No. 18, 1888)
the notes of a case of this rare affection. Briefly stated, they are as follows :
Some days after birth, a general icterus developed, which, in the course of a
few weeks, had disappeared. Two weeks later, without precursory symptoms,
a more or less extensive erythematous eruption showed itself, consisting of
small, closely set red spots. This lasted about a month, and was unac-
companied by any systemic disturbance. A few months later a similar rash
■ented, and as the bright pink or red tint faded, a brownish coloration
was noted. When first seen by Mibelli, the child, a female, was a year old,
and at this time the entire body was covered with numerous pigmented,
slightly elevated spots. These from time to time underwent transitory change,
on certain days, or at different times on the same day, becoming much redder
and more prominent. The case remained under observation for several months
with practically no change in its general features.

Kraurosis Vulva

ases of this curious affection are reported (MtmattkqfU J'iir praktische
Dermatologk, No. 19, 1888) by Janovsky. In their symptoms they corre-
spond with the description of the disease as first given by Breisky in 1885.
The affection involves more especially the labia minora, the inner side of the
labia majora, in fact the entire vestibule region. The affected skin and mucous
membrane appear dry and whitish, the epidermis often thickened, and often
showing enlargement of the small vessels. The appearance suggests a resem-
blance to leucoplakia buccalis. As a secondary result, atrophy takes place, at
times sufficiently great to compromise more or less coitus and childbirth.
Janovsky's cases throw little, if any, light upon the question of the etiology ot

646 PROGRESS OF MEDICAL SCIENCE.

the disease. Treatment also, as in Breisky's experience, appeared without
result.

[A paper on this rare disease was read by Heitzmann at the last meeting of
the American Dermatological Association, the author presenting a method of
treatment having almost invariably a curative result. As soon as published,
an abstract of the same will appear in these columns. — Eds.]

Report on Cultivation Experiments with the Bacillus Leprae.

Beaver Rake has made a series of experiments {British Medical Journal,
August 4, 1888) with the bacillus leprae, and with the following conclusions:

1. At a tropical temperature, and on ordinary nutrient media, I have failed
to grow the bacillus leprae. 2. In all animals yet examined I have failed to
find any local growth or general dissemination of the bacillus after inocula-
tion, whether beneath the skin, in the abdominal cavity, or in the anterior
chamber. Feeding with leprous tissue has also given negative results. 3. I
have found no growth of the bacillus leprae when placed in putrid fluids or
buried in the earth.

OBSTETRICS.

UNDER THE CHARGE OF

EDWARD P. DAVIS, A.M., M.D.,

VI8ITINQ OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL.

The Cause of Occipital Presentations.

Foulis (Edinburgh Medical Journal, September and October, 1888) con-
cludes from the study of sections through the pelvis and abdomen, that the
continual movements of the child's lower limbs in extension, cause the head-
downward position. The prevalence of the situation cf the occiput and back
on the mother's left side results from the proportionally large size of the liver
In the pregnant woman, which fits over the uterus like a cap, affording firm
resistance to the impact of the child's feet.

Two Recent Cases of Symphysiotomy.

MORISANI (Itu/ian Obstetrical and Gynecological Society, September 8, 1888)
reported the case of a rachitic girl, aged fifteen, who was brought to his
eUnic after three days' Ineffectual labor-pains, the foetus presenting in the first
position of the vertex, the left arm prolapsing; the oomjugata vera measured
2.73 inches. Symphysiotomy was done, recovery following. The second case
was a patient aged twenty-five, whose pelvic ootyugata vera measured 2.8
inches; symphysiotomy was performed at the beginning of the ninth month,
successfully. Morisani divided this operation, in Italy, into three periods ; the
first comprised 80 operations; the second, 50; the third (1881-1886) had led
to improved results through antisepsis, and warranted the following deduc-

OBSTETRICS. 647

tions : Estimating the biparietal diameter of the foetal head at 3.7 inches, and
the increase in the eonjvgata vera gained by the operation at 0.85-0.97 of an
inch, it follows that 2.6 inches is the shortest conjugata vera justifying the
operation; when this diameter is 3.12 inches, a cautious attempt at fori
delivery is justifiable, if this fails, symphysiotomy is indicated. The symphy-
siotomy knife is passed from behind forward, to avoid injuring the bladder.

CntRETTA advocated the direct suture of the pubic bones, in place of a
retention-bandage.

An Imi'koyki" .Method of Managing the Third Stage of Labor.

Hart [Edinburgh Medical Journal, October, 1888) believes that the placenta
and membranes separate when a disproportion exists between their area and
their surface of attachment ; this is slight, as the trabecules are microscopic
in size. The placenta, then, separates in the third stage of labor after the
expulsion of the child, and is expelled after its separation by the after-pains ;
manipulation cannot separate the placenta, but can aid in expulsion. His
treatment is as follows: Ergotin and manipulation are used to secure uterine
retraction and empty the intervillous spaces. The child is allowed to cry
freely before the cord is ligated ; the placental portion of the cord drains thor-
oughly before it is tied. These measures hasten the establishment of the
ssary disproportion between the placenta and its surface of attachment,
and favor the rupture of the trabecular When the uterus becomes smaller,
the placenta is separated, and, if necessary, may be expressed. The placenta
should not be separated by efforts at expression; the obstetrician should
maintain the tonicity of the uterine muscle, allow the uterus to separate the
placenta spontaneously, and reserve expression for the expulsion of the
placenta.

The Treatment of Post-partum Hemorrhage by Compression
of the Abdominal Aorta through the Uterus.

In addition to the usual means of checking post-partum hemorrhage,
Sejournet {Annate* de Gyntcotogie, October, 1888) has obtained prompt re-
sults by compressing the abdominal aorta with the hand inserted into the
uterus. He reports five cases of hemorrhage which did not yield to ordinary
means, in which he promptly checked bleeding by this procedure. With
antiseptic precautions this treatment is innocuous. His patients recovered
well.

A Plea for the General Adoption of Antiseptics in Obstetric

Practice.

Cullingworth, in an address at St. Thomas's Hospital, urged upon
English obstetricians the uniform adoption of antiseptics, quoting the statistics
of England and Wales, which showed no diminution in death-rate during the
last twenty years. He employs and commends bichloride of mercury as an
antiseptic, and uses powders, each of which contains ten grains of bichloride
with fifty grains of tartaric acid and one grain of cochineal, to be added to a
pint of water to make a solution of 1 to 1000. As a lubricant he considers

64:8 PROGRESS OF MEDICAL SCIENCE.

glycerine and bichloride, 1000 to 1, convenient and most efficient. — British
Medical Journal, October 6, 1888.

Improved Catheters for Intra-uterine Injections.

Several efforts have been recently made to improve upon the Bozeman
intrauterine catheter commonly used. These efforts have been directed to
securing free return flow, and simplicity and ease of construction and appo-
sition permitting thorough cleanliness.

Kelly (The Medical News, March 14, 1888), Piscasek (Wiener klinische
Wochenschrift, 1888), and Krenet (Centralblattfiir Gyndkologie, No. 39, 1888)
have altered Bozeman's catheter for this end. The elements in these altera-
tions of practical value consist in inclosing a central afferent pipe by a large
efferent pipe, split longitudinally and pierced by apertures for the entrance of
the return flow. The tip should possess lateral apertures only and be perfectly
rounded ; the fastenings be as simple as possible, and each part available for
ocular inspection if possible. In view of the dangers attending the intra-
uterine use of mercury, the catheter may be made of metal, not attacked by
carbolic acid or thymol. Hard rubber is an excellent material for those
employing only mercurial douches.

An Epidemic of Puerperal Sepsis Originating in the Virus of

Angina.

Pfannestiel (Centralblatt fur Oyndkologk, No. 38, 1888) reports four cases
of puerperal sepsis at Breslau, ending in death within from six to eleven days.
The lesions in these cases were diphtheritic endometritis, purulent peritonitis,
and their accompaniments. By exclusion the cause was found to be the virus
of tonsillar angina, conveyed by a midwife whose daughter was ill with this
disease.

Bacteriological study of the cases led to the conclusion that a puerperal
streptococcus cannot be differentiated ; the septic germ of phlegmon, of ery-
sipelas, and of affections of the pharynx, when transplanted upon the geni-
talia of the parturient, causes puerperal sepsis.

The Quarterly Report of the Edinburgh Maternity.
Martin and Havelock report 80 births in the wards, and 181 births in
the patient's homes. These cases were without septic mortality. 3 mothers
died from eclampsia; 1 from placenta prsevia and pneumonia; 1 from pulmo-
nary embolism ; 2 from hemorrhage. Perineal tears were closed with silk-
worm-gut and catgut. Cocaine pessaries were found to be ineffectual to relieve
pain while the cervix was dilating; they seemed partially to anaesthetize the
perineum. Eclampsia was treated by hot packs, cathartics, diuretics, stimu-
lants, and sedatives, with the rapid completion of labor. Barnes's dilators
and forceps were most efficient. — Edinburgh Medical Journal, October, 1888.

A Demonstration of the Deglutition of Liquor Am mi

BY THE FQ2TU8.

Mekus (Centralblattfiir Gi/inikologie, No. 42, 1888) has met with a demon-
stration of the belief that the foetus swallows the liquor amnii in the case of

GYNECOLOGY. 649

a child who could not retain fluid swallowed ; it died of inanition and was
poorly develops! at birth. On examination, the oesophagus was impervious
at its middle. It was noticeable that the liquor amnii was very abundant at
birth. The case is virtually a ligation of the oesophagus in the living foetus;
result, a poorly developed and nourished foetus, no evidence of liquor amnii
in the digestive tract, and an abnormal abundance in utero.

Partial Paralysis of the Upper Extremity following Breech

Presentation.

ltze (Archiv fiir Gynakologie, Band 32, Heft 3) reports the case of a
girl, born in breech presentation, who suffered from complete paralysis of the
greater portion of the right deltoid, biceps, brachial is internus and supinator
longus, the infra-spinatus, and supinator brevis. The right arm had presented
above the head and behind the neck, and the child had been extracted by a
midwife with difficulty.

Schultze considers that violence had been done the brachial plexus at the
point above the clavicle where Erb has described a point at which an electrode,
with the farad ic current, produces contraction in the muscles named.

Acute Tuberculosis Transmitted from Mother to NuMlWQ Child.

Thomson (Eklinburgh MedicalJournal, October, 1888) reports the case of an
infant whose mother died of pulmonary tuberculosis. The child survived but
a few weeks. The mother's breasts and nipples were not tuberculous, and the
child's abdominal viscera were but very slightly affected. The mother had
been noticed frequently coughing in the child's face, and its lungs were ex-
tensively diseased, particularly at the root of the lung, as is usual in children.
Eight weeks before death there was an entire absence of physical signs of the
disease in the child.

GYNECOLOGY.

UNDER THE CHARGE OF

HKNRY C. COE, M.D., M.R.C.S.,

OF H«W YORK.

Acute OZdema of the Skin attending Menstruation and the

Climacteric.

Borner {Med. Chir. Rundschau, July 1, 1888) in a short paper on this
subject quotes from an article of Quincke's, who described a peculiar form of
acute oedema of the skin which had long been known, although its relation
to the sexual organs had not previously been understood. Borner cites a
number of cases which seem to prove that there is a direct causal relation
between this phenomenon and the menstrual and climacteric periods. The
swellings were situated on the face and extremities, and disappeared after a

650 PROGRESS OF MEDICAL SCIENCE.

few hours without leaving any traces of their presence. This occurred in
nervous, but not always in anaemic, patients. The writer thought that they
were due to local vaso-constrictor paralysis, or to reflex irritation of the vaso-
dilators. The congestion became so extreme as to result in effusion. It was
simply a local expression of the general nervous disturbance. Riehl, who
had made similar observations, was of the opinion that the nervous impulse
was of central origin. Borner thought that acute oedema at the menstrual
period was due to a reflex influence transmitted from the genital organs to
the nerve-centre, and then to the peripheral bloodvessels within a certain
area.

The Origin of Epithelial Growths of the Ovary.

Nagel (Arckiv fur Gynakologie, Bd. xxxiii. Heft 1) presents the result* of
his studies of the epithelial ingrowths in the ovary, described by Waldeyer,
de Sin6ty and Melassez, and others. Since these may be seen in every ovary
which is the seat of chronic inflammation, he arrives at the conclusion that
they are directly due to such inflammation, and that they are to be regarded
as the beginnings of epithelial neoplasms, especially cystomata.

On the surface of an ovary which has undergone interstitial changes there
are seen various furrows, resulting from contraction of the fibrous stroma ;
the germinal epithelium normally covering the ovary dips down into these
furrows, forming the epithelial tubes which were formerly supposed to be of
foetal origin. If the edges of such a depression become adherent, a closed
cavity, or pseudo-cyst, is formed containing a fluid secreted by the lining epi-
thelium. In every diseased ovary these small cyscs are found just beneath
the albuginea, and are mistaken for new-formed Graafian bodies, from which.
however, they may be distinguished by noting the following points :

1. The pseudo-cysts are lined with a single layer of regular cubical epithe-
lial cells, while the cells lining a Graafian vesicle are arranged in several
layers ; the latter also contains an ovum.

2. The cysts never have a proper wall ; their cell-lining is directly in con-
tact with the ovarian stroma, while the ovisac has a limiting membrane con-
sisting of two distinct layers.

3. The ovisacs have a regular oval shape, while the cysts are irregular and
have outgrowths, or secondary cysts.

Since the cell-tubes have no limiting membrane, there is nothing to prevent
them from pushing their way deeply into the stroma and throwing out pro-
cesses. There is no ground for supposing that these ingrowths are Identical
in character with Pfluger's tubes ; in fact, the former are observed only in
chronically diseased ovaries, and never in the foetal gland. The writer having
shown that the cell-processes described by him are identical with the ingrowths
observed by Waldeyer, which represent the early stage of epithelial neoplai
inters that the latter must have a similar origin, i. >.. they are due to chronic
Inflammation of the ovary.

The Diagnosis of Chronic Salpingitis in the Early Stage.

Schauta ( Ibid.) says that we seldom have an opportunity to observe the
early stage of tubal disease, since at the examining-table the condition noted

GYNECOLOGY. 651

- or hydrosalpinx, or hypertrophy of the tube. The nodules
ribed by Chiari at the isthmus of the tube, which are due to localized
hypertrophies of the muscularis. represent the result of a catarrhal process
which is most severe at this point, because the lumen is most contracted here,
and consequently the swelling of the mucosa gives rise most quickly to dila-
tation and hypertrophy of the muscular wall. The patient has frequent and
irrt -irular hemorrhages, uterine catarrh, severe pain, and is sterile. The pain
is seldom characteristic, being referable to former perimetritis, although some-
times it is unilateral, and of a peculiar colicky nature. These pains suit
one another at intervals of from fifteen minutes to two hours, and may last
an hour or two ; in the intervals the patient may be quite comfortable. The
pain is due to the spasmodic contractions of the hypertrophied muscularis
at the point of obstruction ; it is naturally most severe at the time of the
menstrual congestion, and often ceases after the flow has become established.
On examination the peculiar nodules at the isthmus of the tube may be felt,
even when the patient is not under the influence of an anaesthetic They are
n<»t readily mistaken for any other condition, and form conclusive evidence
that the inflammatory process has extended from the uterus to the tubes.

As regards the prognosis, it may be stated that in old subjects a cure may
occur spontaneously; in young women, if the tube remains patent, there is
apt to be general hypertrophy in consequence of the stenosis, but if it becomes
closed pyosalpinx develops. Of eighteen cases of mlpingitis Uthmica nodosa
under the writer's care, only five required operations. His technique is
somewhat peculiar. The tubes are entirely separated from the broad liga-
ments, the latter being ligated separately. The fundus uteri is then sur-
rounded by a temporary elastic ligature, while the uterine ends of the tubes,
with the nodules, are entirely dissected away from the uterus, the raw sur-
faces being closed with deep and superficial sutures. In each instance the
patient recovered, and was entirely relieved of the colicky pains from which
she had suffered.

The Relation" between Syphilis and Hysteria.

Charcot (Progrls mid., 1887, No. 51) believes that the tendency to hysteria
may remain latent, as it were, until it becomes active through the influence
of some general infection or toxemia, as syphilis or alcohol. Lead-poisoning
is a potent cause of hysterical manifestations. Severe headache in a syphi-
litic subject, associated with hyperesthesia of the scalp, is usually of hysterical
rather than of specific origin, and is not controlled by antisyphilitic treat-
ment. It may be in these cases that a specific cephalalgia really existed and
was cured, the hysterical symptoms persisting.

Intra-uterine Applications of Chloride of /:

Rheinstadter (CkiUralblattfur Gynakologie , Aug. 25, 1888) states that he
has used chloride of zinc in this way for upward of ten years, and has never
observed any ill effects, especially stenosis of the cervical canal, although he
has made nearly twelve thousand applications. This treatment is especially
applicable to cases of chronic endometritis; ergot, hot-water injections and
glycerine tampons are indicated at the same time. In many instances erosions

652 PROGRESS OF MEDICAL SCIENCE.

can be healed by applications of a strong aqueous solution of chloride of zinc
(50 percent.), so that Emmet's operation may be dispensed with. The caustic
is more efficient than the curette in cases of hyperplastic endometritis, since
the former destroys the submucous as well as the mucous layer. In the writer's
practice, four cases of sterility were treated successfully by cauterizing the
diseased endometrium.

Vomiting and Meteorism after Laparotomy.

Chiara (Ibid., September 22, 1888) has observed that these phenomena
occur more frequently after the removal of diseased ovaries than when larger
abdominal tumors are extirpated. He attributes them to the constriction of
the nerves in the stumps. In the case of large, slowly forming tumors, how-
ever, the nerves undergo a certain amount of stretching, so that they are less
irritable. The symptoms persist until the ligated stump becomes atrophied,
when they cease spontaneously.

The Changes in the Endometrium in Carcinoma of the Cervix

Uteri.

Frankel (Archivfilr Gynakologie, Bd. xxxiii. Heft 1) says that while he
agrees with Abel's deductions, that in all cases of cancer of the cervix the
uterine mucosa undergoes serious changes, he differs from him regarding
the nature of this change. From an examination of six uteri, in which
the cancerous disease had not extended above the cervix, he found that the
appearances presented in sections made through the corporeal endometrium
were those ordinarily observed in chronic endometritis. The interstitial
tissue showed marked changes, especially an increase in the number of spindle-
cells. It is impossible to trace a direct connection between this condition of
the endometrium and the cancer of the cervix. While the writer does not
believe that the former changes are of a malignant nature, he is none the less
of the opinion that in carcinoma of the cervix uteri total extirpation is prefer-
able to high amputation.

CORRIGENDUM.

In Dr. Da Costa's article in our last issue, page 448, 11th line from the bottom,
for " Drop doses of nitro-glycerine " read " Drop doses of a one per cent, solution of
nitro-glycerine."

Mote to Contributors — All communications intended for insertion in the Original
Department of this Journal are only received with the distinct understanding that they
are contributed exclusively to this Journal for publication. Gentlemen favoring us with
tlioir communications are considered to be bound in honor to a strict observance of this
understanding.

Liberal compensation is made for articles used. Extra copies, in pamphlet form, if
desired, will be furnished to authors in lieu of compensation, provided the request for
them be written on the manuscript.

INDEX.

ABDOMINAL parietes, separation of, fol- 1
lowing laj>arotomy, 303

Abortion, treatment of, 2t>0. 429

Abscess of left temporal lobe, 637

Abscess, retro-pharyngeal, external inci-
aions in, 96

Aeetanilide, 287

Acetic acid, an antiseptic in obstetrics, 428 j

Aconitia, use of, 288

Albuminuria of pregnancy, 206. 429

Albuminuria, salicylate of sodium in, 68

Alcoholic poisoning, 327

Alexander's operation, modification of, 323

Ammonia, antiseptic properties of, 51 !

Amputations, major, results of, 633

Anaemia, pernicious, 618

Antidote, a general, 291

Antifebrin in nervous diseases, 613

Antipyrin as an analgesic, 176, 404

Antipyrin in chorea, 177

Antipyrin in pertussis, 68, 176, 51a

Antipyrin, suppression of milk by. IM

Antipyrin versus analgesine, 68
iternal, 290

Antisepsis, obstetric, 543, 647

Antiseptic solution, 616

Anus, imperforate, 82

Aortic system, narrowness of,

Aphasia relieved by operation, 527

Aprosexia, nasal, 638

Arthralgia, 633

Arthrectomy, 87

Ascites as a symptom of tension of the ped-
icle of ovarian cyst, MM

Astasia and abasia, an affection character-
ized by, 518

Asthma, 246

ma, treatment of bronchial, 129

Ataxia, Friedreich's, 377

Atomic weight and biological action. »;.*■

Aural reflexes, 637

Auricle, syphilide of, 90

BASEDOW'S disease, 622
Benign growths, transformation ol. into
malignant, 314

Bestiality.

Bile, action of drugs on, 399

Births, precipitate, 317

Bismuth, salicylate of, 286

Bladder, injury to, during laparotomy, 216

Blood, effects of non-oxygenation of

maternal, upon foetus, 548
Blood-pressure in renal disease, 186
Boils, nitrate of mercury for, 203
Boric acid in antisepsis, 510
Bosworth, asthm:i
Brachycardia, 299

Brain, abscess in temporo-frontal lobe, 536
Brain, subdural abscess of,
Bright's disease, arteries and veins in, 525
Bright's disease, etiology of, 525
Broncho-pneumonia, treatment of, 409

CESAREAN section, 99, 209, 465, 544, 545
Caffeine as a cardiac tonic, 291
Caffeine in lung diseases, 408
Calcium chloride in skin diseases, 644
Calomel, a diuretic, 175
Camphoric acid, 617. 0 J I
Cancer, prognosis of, 302
Canula, tracheal, for goitre, Ml
Carcinoma, prognosis of, 627
Cardiac degeneration from pressure, 298
Carlsbad water, action of, 290
Catarrh, nasal, treatment of, 69
Catgut, sterilization of, 400, 618
Catheter for intra-uterine injections, 648
Caustics on nasal mucous membrane, 97
Cephalalgia from intranasal disease, 316
Cerebellum, abscess of, from ear disease, 200
Cerebral surgery, 25. 109, 219, 329, l
Cholecystenterostomy, 418
Chloride of zinc as an eachaiotie, 432
Chloroform water, antiseptic, 289
Cholecystotomy, 191
Chorea, antipyrin in, 177
Chorea, rapidly fatal, 518
Chyluria, pathology of, 187
Club-foot, treatment of, 532
Cocaine, 177, 288, 508
Cocaine habit, treatment of, 622
Cocaine in general ana -
Cocaine subcutan-

654

INDEX.

Codeine in abdominal pain, 176

Cod-liver oil, absorption of, 509

Cohen, stricture of larynx, 597

Colotomy, technique of, 196

Colpitis emphysematosa, 323

Comedones, peculiar eruption of, 202

Conjunctivitis aestivalis, 309

Constipation in children, 411

Cornea, congenital clouding of, 570

Coryza, parasitic nature of, 315

Cough, choreic, methyl chloride in, 537

Creasote water in tuberculosis, 624

Creolin, 288, 513

Croom, removal of uterine appendages, 577

Cyst, sub-hyoid, 97

Cyst, vaginal, 323

Cystic tumors, operation before opening, 323

Cystonephrosis, 191

Cystotomy, supra-pubic, 197

DABNEY, epidemic resembling dengue,
488
Da Costa, treatment of valvular disease,

439, 652
Deaver, removal of motor centres in focal

epilepsy, 477
Deaver, removal of tumor of spine, 564
Delivery of the after-coming head, 207
Dengue, epidemic resembling, 488
Diabetes, codeine and morphine in, 512
Diarrhoea, treatment of infantile, 527
Digestion, influence of bacteria on, 429
Diphtheria, treatment of, 406, 514
Diphtheritic throat in scarlet fever, 70
Donders Festschrift, 3 1 1
Drainage, peritoneal, by iodoform wick, 103
Drowning, water in stomach a sign of, 327
Duhring, impetigo simplex, 374
Dysentery, paralysis in, 77
Dyspnoea, cardiac, 410
Dystocia caused by fibroids, 209
Dystrophia muscularis, 408, 620

EAR, boils of, 89
Bar, diseases of, 89
Ear, disease of middle, complicate, i by intra-

cranial lesions, 93, 534
Bar, foreign bodies in, 533
Ear, syphilis of, 532, 534
ihereulosis of, 91

arium, 6 l-

acture of, 420

Embryotomy, 317

Endometrium in carcinoma of cervix, 107

Endocarditis from pneumococci, 185

Endometritis, cauterizing in, 321

Enteritis, sublimate, 186

Ephedrin, 403

Epiglottis, anatomy of, 539

Epilepsy, aural, 89, 636

Epilepsy, focal, excision of motor centres

in, 477
Epilepsy, gastric, 180
Epilepsy, mortality of, 73
Epistaxis, cocaine in, 640
Eruption, post-vaccinal, 424, 643
Erythrophloein, action of, 613
Exostosis, ivory, of auditory canal, 90

FALLOPIAN tube, carcinoma of, 218
Febrile diseases, outbreak of, 437

Fibula, luxation of, 86

Filaria sanguinis hominis, 188

Fistula?, cervico-vesico-vaginal, 213

Fistulas, recto-vaginal, 103

Fistula?, vesico-vaginal, 104, 213
! Foetal nutrition, 319
| Foetal positions, frequency and causes of, 99

Foot, ostsoplastic resection of, 633

Forceps, axis-traction, 427

Forceps, compressing, 543

Fmvhheimer, fatty overgrowth of heart, 549

Forehead, wound of, in a newborn. Ill

Furunculosis, post-eczematous, 425

GANGRENE of skin, 424, 643
Gastroenterostomy, 304, lit
' Genitals, female, disinfection of, 128
i Glandular affections of neck, aalfdnrn chlo-
ride in, 526
Glottis, paralysis of dilators of. 540
Glycerine in constipation, 176, 625
Gonorrhoeal rheumatism, 88
Griffith, Friedreich's ataxia, 377

H^EMATURTA simplex in a newborn. 7S
Ilivmoptysis, iodoform in, 511
Hand, horny growth of, 644
Hamlford, perforating ulcers of fee
Harris, extrauterine pregnane]
II. i.l. delivery of the aftercomim;. W1
Bead presentations, rotation in, 207
Headache, acids and antUebrio in, 179

he. salievlate of sodium ill, 180

Headache, uric aei.1. 7'.'

Heart, afleotioni of, In tabes, 183

INDEX.

', determination of limits of,
I disease and diabetes, 183

' ro-glycerine in, 299
Heart, fatty overgrowth of, 1*4, 549

, valvular disease of, 439
Hemorrhage in amputation of shouider-

joint, checking.
Hemorrhage, irregular uteris

■ «rrhage, treatment of post-partim
Hemorrhoids, 306

ia into foramen of Winslow, 631
Hernia, radical operation for reducible
Herpes areolaris mamms?, 425
Herpes ophthalmicus, 645
Herpes zoster femoralis, recurrent. 422
Hicks, bodily movements and sep?
Hun, myxcedema. 1. 140
Hydat items, 101

Hydatids, abdominal, obstructing lab 1
Hydramnios, 101
Hydrocele, radical cure of, 156

^>'EE^^ cerebral surgery, 329, 452
k Kidney, influence of, on bladder
symptoms, 82
Kraurosis vulva*, 645

Kreuznach mother-liquor in skin diseases,
644

LABOR, management of, 647
Labor, missed, 206
Labyrinth, alterations in, in measles, 94
Lactic acid in otitis, 92
Lactic acid in tuberculous ulceration and

lupus, 644
Laparotomy, 108, 209, 318
Laparotomy in peritoneal tuberculosis, 190
Laparotomy, second, in same patient, 322
Laryngeal chorea. 537
Laryngeal phthisis. 538
Laryngectomy, 539, 639
Larynx, cancer of. 314
Larynx, gunshot wound of, 538
Larynx, influence of diathesis on, 313

Hydrocyanic acid, illness from inhalation Larynx, occlusion of, 640

of, 328
Hydrofluoric acid in phthisis, 409,623
■^en gas in intestinal wounds, 81
Hymen, imperforate, 204

-oine, 403
Hypnotic, method of testing, 509
rical fever, 70

ICHTHYOL, 405
Icterus, febrile, 516
Icterus gravis, 300

go simplex, 374
Insomnia, sulphonal in, 407
Instruments, disinfection of, 188
Intestinal obstruction after laparotomy, 217
433

tribatioB to, 193

; Larynx, stricture of, 538, 597
Larynx, syphilis of, 538
Larynx, tubercular tumors of, 539
Larynx, ulceration of, in typhoid fever, 539
Lead-poisoning, epidemic of, 328, 436

; Lepra, bacillus of, 646
Leucocythtemia preceded by deafness and

facial paralysis, 201
Leukaemia, pathology and treatment of, 71
Lichen ruber planus, 643
Liquor amnii, deglutition of, by foetus, 648

; Lithotrity, perineal, 629
Liver, action of spirits on, 55

I Liver, fixation of movable lobule of, 190
Liver, tongue-like extension of, 41 ^
Lloyd, focal epilepsy, removal of motor
centres in. 477

Intestinal wound-, insufflation of hydrogen Lloyd, removal of tumor of spine, 564

gas in, 81

Intestine, cancer of, extirpation of, 305
Intussusception relieved by hydrostatic

pressure, 78
Iodoform, bituminated, 401
Iodoform, deodorized, 402
Iodoform, preset. 400

Iodoform tamponade, 301
Iodol in otitis media purulenta, 91
Ischuria, puerper.

JACOBSON. cancer of tongue, 232
Jay, Ciesarean section, 465
Johnston, duodenal ulcer, 42
Joints, intermittent dropsy of, 526

Lochia, bacteria h.
Lung surgery, 78
Lupus, 203

Lupus of hand, erythematous, 583
treatment of. 423, 617

ream, 69
Malleus, removal of, 92
Mania following operations, 591
Mastitis, puerperal, 98
Measles, incubation of, 70
Meco-narceine, 66
Medicines, administration of, 286
Melanotic tumors of female genitals, 431

656

INDEX

M6nie'res disease, 535

Meningitis, cerebral, treatment of, 618

Meningitis, epidemic eerebro-spinal, 517

Menstruation after oophorectomy, 216

Menthol plaster, 69

Mercury bichloride, accidents with, 101

Mercury bichloride in obstetrics, 542

Mercury, diuretic action of salts of, 614

Mercury oxycyanide, best of antiseptics, 288

Mercury, succinamide of, 616

Methylal, 285

Microorganisms in genital canal, 319

Migraine, phenacetin in, 621

Milk, suppression of, by antipyrin,404

Morphia habit, treatment of, 622

Morris, radical cure of hydrocele, 156

Movements, influence of, on sepsis, 37

Mucous membrane grafts, 189

Mucous membrane, nasal, action of caustics

on, 97
Muscular atrophies and hypertrophies, 295
Myoma and myomectomy, 215
Myoma of uterus, laparotomy for, 108
Myopathy, progressive, 407
Myxoedema, 1, 140, 621

NEPHRITIS, glomerular. 626
Neurasthenia, arterial tension in, 72
Neuritis fascians, 621
Neuritis, peripheral, in rheumatism, 292
Nitro-glycerine in heart failure, 299
Nodules, subcutaneous, in arthritis, 405
Nursing bottles, danger of metal in, 211
Nurslings, influence of drugs taken by
nurses on, 320

OBSTETRIC practice, modern, 541. 542,
648
Obstruction, intestinal, 217,433
(Edema of skin, circumscribed, 424, 649
(Esophagus, stricture of, 540
(Esophagotomy, 638
Oleander, 66

Oophorectomy, Cesarean section with, 465
Ohmann Damacail, lupus of hand, 583
Ophthalmia neonatorum, prevention of, 320
Ophthalmometer, new, 308
Osteomalacia, castration in, 433
Otitis due to traumatism, 635
Otitis, lactic acid in, 92
Otitis media hemorrhagica, 635
Otitis media, todol in. yi
Ovarian tumors, rotation of, 357
Ovariotomy second day after delivery, 105
v, degeneration of, 105

Ovary, epithelial growth of, 650
Oxycyanide of mercury, an antiseptic, 3

PALSIES, birth, 102, 293, 649
Papilloma, laryngeal, unusual case of,
97, 639
Paralysis, central, of children, 518, 520
Paralysis in dysentery, 77
Paralysis of sixth nerve, 311
Paramyoclonus multiplex, 180
Parturition among the poor, 101
Parturition, signs of, after recovery, 548
Patella, treatment of fracture of, 84, 419, 634
Pemphigoid eruption, with changes in

peripheral nerves, 422
Pemphigus pruriginosus, carbolic acid in.

421
Peritonitis, purulent, drainage in, 319
Pharyngitis, infectious phlegmonous, 94,.

640
Phenacetin, 177, 405, 507
Phenacetin in migraine, 621
Phonation after laryngectomy, 641
Phthisis, creasote and iodide of potash in,

523, 624
Phthisis, hydrofluoric acid in, 409, 623
Phthisis treated by calomel, 623
Phthisis, treatment of, by oxygen, 182
Photoxylin solution in perforation of mem-

brana tympani, 91
Pilocarpine, 403
Placenta, development of, 546
Placenta pnevia, air embolism in, 319
Placenta, retention of, 547
Placenta, separation of, 207
Pleurisy a cause of phthisis, 297
Pleurisy complicating ovarian cyst, 433
Pleurisy, treatment of effusion of, 181
Pneumonia, 73, 74

Pneumonia, large doses of digitalis in, 514
Pneumonia, rheumatic, 181
Pneumonia, tartar emetic in, 522
Polypus, laryngeal, expulsion of, 96
Polyuria, antipyrin in, 404
Porencephalus, 620
Pregnancy and fibro-myoraata, 209
Pregnancy and ovarian cyst, 102
Pregnancy complicated by fibroids, 210
Pregnancy complicated by carcinoma of

cervix, 208
Pregnancy, extra-uterine, 101, 210, 262,318,

426, 427
Pregnancy, multiple, 317, 543
Pregnancy, ruptured tubal, 99, 102, 426,
545, 546

INDEX.

657

Pregnancy, with gangrenous ovarian •

99
Presentations, occipital, 646
Prudd.-n, nivxn.l.'ina. 1
Pruritus hidii, menthol in, 513
Psychoses following gynecological opera- 1

tions. 113
Psychoses, puerperal, and septic infection.

547
Ptomaine poisoning during pregnancy, 205
Puerperal fever, spread of, 428
Puerperal sepsis, 648
Pupillary changes in chronic pulmonary

disease, 311
Pyaemia after abortion, 429
Pyo-salpinx, observations on, 107

RANDOLPH, clouding of cornea, 570
Rectum, carcinoma of, 82

Rectum, prolapsed, operative treatment of,
197

Rectum, extirpation of, 305

Recurrent fever, pathology of, 619

Reflexes, aural and oto-spinal, 637

Resorcin in eczema, 202

Respiration, nasal, impeded, 636

Responsibility, medical, 324

Resuscitation of newborn, 211

Reviews —

Bell, Manual of Operative Surgery, 171
Billings, Census -Mortality Report, 279
Bramwell, Intra-cranial Tumors, 502
Buxton, Anaesthetics, 500
Carter, Ophthalmic Surgery, 59
Delorme, Surgery of War, 56
Ewald, Diseases of the Stomach, 496
Fenwick, Electric Illumination of

Bladder, 610
Foster, Medical Dictionary, 392
Gairdner and Coats, Lectures, 395
Guelpa, Treatment of Diphtheria, 170
Hirst, System of Obstetrics, 275
Hofmeier and Benckiser, Anatomy of

Pregnant Uterus, 398
Hyde, Diseases of the Skin, 55
Jacobi, Intestinal Diseases of Infancy,

63
Jacobi, M. Putnam, Hysteria, 604
Johnson, Lectures and Essays, 396
Keyes, Genito-urinary Surgery, 62
Lawson, Epidemic Influences, 605
McLachlan, Anatomy of Surgery, 506
Mitchell, Dissolution and Evolution

and the Science of Medicine, 172
National Formulary, 505

Reviews —

Pilcher, Transportation of Disabled,

398
Remsen, Theoreti. ;.l el,,.,
Roose, Gout, 165
Smith, Abdominal Surgery, 169
Stewart, Important Symptoms, 601
Stimson, Dislocations, 389
Suzor, Hydrophobia, 63
Taylor, Atlas of Venereal Diseases, 495
Tyson, Examinations of Urine, 284
Vaughan and Novy, Ptomaines, 394
Waxham, Intubation of Larynx, 504
Williams, Cancer Formation, 397
Witkowski, Atlas of Gestation, 64
Wolfenden, Pathological Anatomy of

Papilloma, 172
Yeo, Uric Acid Diathesis, 165
Rheumatism, treatment of, 179, 293, 514
Rotation in head presentation, 207

O ACCHARIN, 287. Ml
O Salivary glands, inflammation of, fol-
lowing labor,
Salpingitis, diagnosis of chronic, 650
Scarlatina in pregnancy, 205
Scarlet fever, diphtheritic throat in, 70
Sebaceous tumors, treatment of, 423
Seguin, cerebral surgery, 25, 109, 219
Sepsis, influence of bodily action on, 37
Septicaemia, intestino -peritoneal, 413
Septicaemia, puerperal, 100, 318
Shepherd, mania following operations, 591
Shoulder, irreducible luxation of, 634
Simulo as an antiepileptic and anti hysteric,

512
Skin, transplantation of, 301, 424
Skull, fracture of, 307
Skull, perforation of, in childhood, 406
Sozoiodol, 402

Sphenoidal sinus, disease of, 316
Spinal cord, excision of tumor of, 189, 564
Spine, railway, 632
Spleen, dislocation of, 302
Spleen, extirpation of, 302, 529
Starch, glycerite of, as a dressing, 613
Sterility in men, 417
Sterility, one-child. 212
Stomach diseases, chemical diagnosis of, 76
Stomach, ulcerative perforation of, 415
Stomach, water in, as a sign of death by

drowning, 327
Stomatitis, naphthol in, 526
Stricture, urethral, curability of, 630
Strophanthus, diuretic action of, 511

658

INDEX.

Sulphonal, 67, 285, 407, 508, 516
Surgery, intestinal, 193
Surgery, pulmonary, 78
Symphysiotomy, 646
Symphysis pubis during labor, 544
Symphysis pubis, partial resection of, 629
Syphilis, abortive treatment of, 627
Syphilis and hysteria. 651

1 TEETH, painless extraction of, 177
Tetany, 521

Thoracotomy 'or sarcoma, 628

Thornton, n tatiou of ovarian tumors, 357

Thrush in middle ear, 93

Tongue, cancer of, 232

Tonsil, abscess of stump of ablated, 315

Tonsil, removal of carcinomatous, 531

Tonsillitis, M

Tracheitis, fetid, 689

Tracheotomy for sarcoma of chest wall, 628

Tracheotomy versus intubation, 680

Transplantation of skin, 424

Tubal pregnancy twice in same patient, 102

Tubercle bacilli, diffusion of, 75

Tubercle bacilli, influence of hydrofluoric-
acid on 623

Tuberculosis transmitted to offspring, 649

Tumors, abdominal, diagnosis of, 412

Tumors, ovarian, rotation of, 357

Tumors, sebaceous, treatment of, 423

Tympanum, influence of pilocarpine on, 535

Tympanum, perforations of, photoxylin
solution in closing, 91

Typhlitis, saline purgatives in, 187

Typhoid fever in children, 69

Typhoid fever, treatment of, 178, 290, 292

ULCERS, duodenal, simple, 43
Ulcers of feet, perforating, 257
Ulcers, gastric, diagnosis and treatment of,

186
Ulcers, chronic leg, massage in. 481
te, catheteriaatioD of, 630

Urethra, dilatation of, 105, 324

Urethrotomy, internal antiseptic, 630

Urticaria pigmentosa, 423, 646

Uterine appendages, removal of, 577

Uterine segment, lower, 100

Uterus, adengma of, 213, 431

Uterus, carcinoma of, with tihro-myoma,

432
Uterus, carcinoma of cervix of, 208
Uterus, changes in endometrium in carci-
noma of cervix of, 652
Uterus, double, 205
Uterus, hydatid cysts of, 101
Uterus, involution of puerperal, loo
Uterus, prolapsed, operation for, 214
Uterus, retrollexed, treatment of, 321
Uterus. Bupra-vaginal amputation of, 214,
322

VACCINATION statistics in Germs
Vagina, double, 205
Vaginismus, cocaine in, 617
Venereal diseases, treatment of 67
Version before labor, 20ti
Vomiting after laparotomy, 652
Vomiting in pregnancy, 426
Vulvo-vaginitis in children, 430

WASHING medl
Weil's disease, 516

Weir, cerebral surgery, 25, 109, 219

Whooping-cough, abortion of, 406. 515

Whooping-cough, antipyrin i

Williams, bronchial asthma, 129

Wound treatment, 88, 626

Wound of newborn children occurring

during vaginal examination, 21 1
Wry-neck, incision in.

ZINC chloride, an eecharotic, IS2, HI
Zinc industry, its inflnanw m health
130

662-4

inta dtU I . rw\ t duo

R The American journal of the
fi medical sciences

A5
n.s.
v.96
cop. 2

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